MEDICARE: TRI COUNTY PET LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center	HCC5507	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124020656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI COUNTY PET LLC

Provider Business Mailing Address
First Line	:	1150 N 35TH AVE
Second Line	:	SUITE 665
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-5424
Country	:	US
Telephone Number	:	954-981-6668
Fax Number	:	954-981-5944

Provider Business Practice Location Address
First Line	:	1150 N 35TH AVE
Second Line	:	SUITE 665
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-5424
Country	:	US
Telephone Number	:	954-981-6668
Fax Number	:	954-981-5944

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	LISETTE CRUZ-DENO
Credential	:
Telephone Number	:	954-981-6668

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	12/12/2013

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Directions to “TRI COUNTY PET LLC ” Practice Location

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