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General NPI Number Information
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NPI Number | 1255789368
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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 | 05/31/2016
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Last Update Date | 05/31/2016
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Provider Practice Location Address
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Address Line | 1485 PINE RIDGE ROAD UNIT #1
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City | NAPLES
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State | FL
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Zip | 34109
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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 | MEDICAL DIRECTOR IDEAL IMAGE
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Name | DR. KRISTON KENT
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Credential | M.D
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Telephone | 239-514-7888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 3063932
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License Number State | FL
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