=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316673668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVENTHEALTH IMAGING CENTER PORT ORANGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2022
-----------------------------------------------------
Last Update Date | 07/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5821 S. WILLIAMSON BLVD SUITE 101
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-231-2951
-----------------------------------------------------
Fax | 386-231-2952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5821 S. WILLIAMSON BLVD SUITE 101
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-231-2951
-----------------------------------------------------
Fax | 386-231-2952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/CFO
-----------------------------------------------------
Name | MICHAEL MAZERES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-200-2227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------