Healthcare Provider Details

I. General information

NPI: 1235148578
Provider Name (Legal Business Name): PET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 N 9TH AVE STE 124
PENSACOLA FL
32504-8756
US

IV. Provider business mailing address

5149 N 9TH AVE STE 124
PENSACOLA FL
32504-8779
US

V. Phone/Fax

Practice location:
  • Phone: 850-478-6336
  • Fax: 850-478-6361
Mailing address:
  • Phone: 850-478-6336
  • Fax: 850-478-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number3670 1
License Number StateFL

VIII. Authorized Official

Name: CLARK M. POLLITT
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 850-478-6336