Healthcare Provider Details

I. General information

NPI: 1215049614
Provider Name (Legal Business Name): INDIAN RIVER MRI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 37TH ST
VERO BEACH FL
32960-4856
US

IV. Provider business mailing address

1850 37TH ST
VERO BEACH FL
32960-4856
US

V. Phone/Fax

Practice location:
  • Phone: 772-562-3030
  • Fax: 772-778-0766
Mailing address:
  • Phone: 772-562-3030
  • Fax: 772-778-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME45770
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberHCC5552
License Number StateFL

VIII. Authorized Official

Name: MR. RONALD COOPER
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 772-562-3030