=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457724379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH FLORIDA NUCLEAR GROUP, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2015
-----------------------------------------------------
Last Update Date | 11/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14889 INDIGO LAKES DR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34119-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-723-6224
-----------------------------------------------------
Fax | 239-732-1145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14889 INDIGO LAKES DR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34119-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-723-6224
-----------------------------------------------------
Fax | 239-732-1145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DAVID SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-723-6224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------