Healthcare Provider Details

I. General information

NPI: 1760424071
Provider Name (Legal Business Name): EAST CENTRAL FLORIDA OUTPATIENT IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SOUTHPARK BLVD SUITE 101
ST AUGUSTINE FL
32086-4120
US

IV. Provider business mailing address

1673 MASON AVE SUITE 305
DAYTONA BEACH FL
32117-5515
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-0764
  • Fax: 904-829-2221
Mailing address:
  • Phone: 386-274-7118
  • Fax: 386-274-6173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StateFL
# 8
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. AL FALCO
Title or Position: CEO
Credential:
Phone: 386-274-7118