Healthcare Provider Details

I. General information

NPI: 1407001902
Provider Name (Legal Business Name): IMIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15202 SW 80TH AVE
PALMETTO BAY FL
33157-2202
US

IV. Provider business mailing address

15202 SW 80TH AVE
PALMETTO BAY FL
33157-2202
US

V. Phone/Fax

Practice location:
  • Phone: 305-235-9920
  • Fax: 305-675-7836
Mailing address:
  • Phone: 305-235-9920
  • Fax: 305-675-7836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: DR. BORIS NIKOLOV
Title or Position: CEO
Credential: MD
Phone: 305-235-9920