=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750382198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE IMAGING OF ST LUCIE COUNTY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 66TH AVE SW
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32968-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-569-9729
-----------------------------------------------------
Fax | 772-569-2769
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 66TH AVE SW
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32968-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-569-9729
-----------------------------------------------------
Fax | 772-569-2769
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ROSANNA CRAWFORD
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 772-569-9729
-----------------------------------------------------
=====================================================
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 | JR28288000
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------