=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326446758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMMANUEL'S IMAGES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2014
-----------------------------------------------------
Last Update Date | 12/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 954 LAKE BALDWIN LN
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32814-6651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-832-5066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1746 E SILVER STAR RD STE 121
-----------------------------------------------------
City | OCOEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34761-7014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | AUDREY FEDRICK
-----------------------------------------------------
Credential | BS, RDMS, RDCS, CCT
-----------------------------------------------------
Telephone | 407-832-5066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NT0100X
-----------------------------------------------------
Taxonomy Name | Thermography Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------