=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992260566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRECIOUS MOMENTS 3D - 4D LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2019
-----------------------------------------------------
Last Update Date | 06/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5336 US HIGHWAY 98 N
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33809-0517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-816-3870
-----------------------------------------------------
Fax | 863-434-7586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5336 US HIGHWAY 98 N
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33809-0517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-816-3870
-----------------------------------------------------
Fax | 863-434-7586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. PAMELA MARIA GUTIERREZ
-----------------------------------------------------
Credential | RDMS
-----------------------------------------------------
Telephone | 863-529-7448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2471S1302X
-----------------------------------------------------
Taxonomy Name | Sonography Radiologic Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------