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General NPI Number Information
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NPI Number | 1255573002
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Entity Type | Organization
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Legal Business Name | PRUDENTIAL DIAGNOSTIC CENTER CORP.
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Dates
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Enumeration Date | 03/25/2009
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Last Update Date | 04/29/2009
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Provider Practice Location Address
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Address Line | 900 W 49TH ST 308
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City | HIALEAH
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State | FL
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Zip | 33012-3402
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Country | US
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Telephone | 305-827-9140
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Fax | 305-827-9143
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Provider Business Mailing Address
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Address Line | 900 W 49TH ST 308
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City | HIALEAH
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State | FL
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Zip | 33012-3402
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Country | US
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Telephone | 305-827-9140
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Fax | 305-827-9143
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUAN C PEREZ
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Credential | DO
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Telephone | 305-827-9140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | HCC7306
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License Number State | FL
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