Healthcare Provider Details

I. General information

NPI: 1700056009
Provider Name (Legal Business Name): ACTIVE DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 W GRAY ST
TAMPA FL
33609-1516
US

IV. Provider business mailing address

PO BOX 320905
TAMPA FL
33679-2905
US

V. Phone/Fax

Practice location:
  • Phone: 813-348-0049
  • Fax:
Mailing address:
  • Phone: 813-348-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberL08000017078
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License NumberL08000017078
License Number StateFL

VIII. Authorized Official

Name: MISS JESSICA VILLEGAS
Title or Position: PRESIDENT
Credential: RDMS
Phone: 813-348-0049