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General NPI Number Information
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NPI Number | 1083008437
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Entity Type | Organization
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Legal Business Name | IDEAL IMAGE
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Dates
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Enumeration Date | 03/24/2015
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Last Update Date | 03/24/2015
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Provider Practice Location Address
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Address Line | 1485 PINE RIDGE RD
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City | NAPLES
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State | FL
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Zip | 34109-2114
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Country | US
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Telephone | 239-596-2005
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Fax | 239-596-1090
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Provider Business Mailing Address
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Address Line | 1485 PINE RIDGE RD
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City | NAPLES
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State | FL
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Zip | 34109-2114
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Country | US
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Telephone | 239-596-2005
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Fax | 239-596-1090
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MS. EMILY LAESER
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Credential | ARNP
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Telephone | 239-596-2005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 9286385
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License Number State | FL
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