MEDICARE: ACTIVE DIAGNOSTIC 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	2471V0105X	Vascular Sonography Radiologic Technologist	L08000017078	FL
2	2471S1302X	Sonography Radiologic Technologist	L08000017078	FL

General Provider Information

NPI Number	:	1700056009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE DIAGNOSTIC IMAGING LLC

Provider Business Mailing Address
First Line	:	PO BOX 320905
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33679-2905
Country	:	US
Telephone Number	:	813-348-0049
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 W GRAY ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-1516
Country	:	US
Telephone Number	:	813-348-0049
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS JESSICA VILLEGAS
Credential	:	RDMS
Telephone Number	:	813-348-0049

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/04/2008

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