Healthcare Provider Details

I. General information

NPI: 1942499108
Provider Name (Legal Business Name): IMAGING DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C/42 S.E #1000 REPARTO METROPOLITANO
SAN JUAN PR
00921
US

IV. Provider business mailing address

100 GRAND BOULEVARD PASEOS PMB 439 SUITE 112
SAN JUAN PR
00926-5902
US

V. Phone/Fax

Practice location:
  • Phone: 787-751-6400
  • Fax: 787-523-1735
Mailing address:
  • Phone: 787-751-6400
  • Fax: 787-523-1735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number171164
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number171164
License Number StatePR

VIII. Authorized Official

Name: FERMIN GUERRA
Title or Position: ADMINISTRADOR
Credential: CPA
Phone: 787-645-7523