Healthcare Provider Details

I. General information

NPI: 1104669647
Provider Name (Legal Business Name): RADIOLOGY IMAGING ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ORTHOPAEDIC PL
ST AUGUSTINE FL
32086-4202
US

IV. Provider business mailing address

PO BOX 161997
ALTAMONTE SPRINGS FL
32716-1997
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CALEB RUBEN RIVERA
Title or Position: MD
Credential:
Phone: 352-671-4221