MEDICARE: INDEPENDENT IMAGING, 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	:	1508233487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT IMAGING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1313
Second Line	:
City	:	LOXAHATCHEE
State	:	FL
Zip	:	33470-1313
Country	:	US
Telephone Number	:	561-795-5558
Fax Number	:	561-792-7300

Provider Business Practice Location Address
First Line	:	701 S MAIN ST
Second Line	:
City	:	BELLE GLADE
State	:	FL
Zip	:	33430-4201
Country	:	US
Telephone Number	:	561-795-5558
Fax Number	:	561-792-7300

Authorized Official
Title or Position	:	CEO
Name	:	JORGE DANIEL GHIRAGOSSIAN
Credential	:
Telephone Number	:	561-766-1300

Provider Enumeration Date	:	08/27/2015
Last Update Date	:	09/10/2015

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