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General NPI Number Information
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NPI Number | 1609156231
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Entity Type | Organization
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Legal Business Name | EXECUTIVE DIAGNOSTIC CENTER
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Dates
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Enumeration Date | 08/26/2011
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Last Update Date | 08/26/2011
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Provider Practice Location Address
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Address Line | 5211 NW 79TH AVE
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City | DORAL
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State | FL
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Zip | 33166-4715
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Country | US
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Telephone | 305-994-7343
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Fax | 305-994-7346
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Provider Business Mailing Address
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Address Line | 5211 NW 79TH AVE
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City | DORAL
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State | FL
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Zip | 33166-4715
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Country | US
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Telephone | 305-994-7343
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Fax | 305-994-7346
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. LEIDY DIAZ
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Credential | OWNER
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Telephone | 305-994-7343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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