=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427051887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA DIAGNOSTIC PORTABLE IMAGING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 06/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5201 BABCOCK ST NE STE 2
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32905-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-984-8001
-----------------------------------------------------
Fax | 321-728-0523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5201 BABCOCK ST NE STE 2
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32905-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-984-8001
-----------------------------------------------------
Fax | 321-728-0523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRUCE D COTTI
-----------------------------------------------------
Credential | R.T.(R)
-----------------------------------------------------
Telephone | 321-984-8001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------