MEDICARE: VITAL IMAGING DIAGNOSTIC CENTERS 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

General Provider Information

NPI Number	:	1467929364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL IMAGING DIAGNOSTIC CENTERS LLC

Provider Business Mailing Address
First Line	:	7101 SW 99TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33173-4661
Country	:	US
Telephone Number	:	305-596-9992
Fax Number	:

Provider Business Practice Location Address
First Line	:	3146 CORAL WAY
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33145-3210
Country	:	US
Telephone Number	:	305-559-6999
Fax Number	:

Authorized Official
Title or Position	:	MGRM
Name	:	JUAN PUIG
Credential	:
Telephone Number	:	305-596-9992

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/29/2018

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