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General NPI Number Information
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NPI Number | 1720382427
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Entity Type | Organization
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Legal Business Name | IDEAL DIAGNOSTIC CENTER INC
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Dates
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Enumeration Date | 01/10/2011
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Last Update Date | 01/12/2011
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Provider Practice Location Address
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Address Line | 3623 SW 3RD ST
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City | MIAMI
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State | FL
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Zip | 33135-2543
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Country | US
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Telephone | 305-444-0137
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Fax | 305-444-0137
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Provider Business Mailing Address
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Address Line | PO BOX 350966
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City | MIAMI
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State | FL
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Zip | 33135-0966
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Country | US
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Telephone | 305-444-0137
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Fax | 305-444-0137
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | INGRID CIFUENTES BRUCE
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Credential | LMT
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Telephone | 305-444-0137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | MA 61215
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License Number State | FL
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