=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932773256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGINE MEDICAL INTERNATIONAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2021
-----------------------------------------------------
Last Update Date | 05/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10151 DEERWOOD PARK BLVD STE 200-250
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-486-0746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10151 DEERWOOD PARK BLVD STE 200-250
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-486-0746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF CLINICAL OFFICER
-----------------------------------------------------
Name | DR. AVANIKA KHANNA GROVER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 469-323-9093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------