Provider Demographics
NPI:1003318049
Name:TRI COUNTY PET LLC
Entity Type:Organization
Organization Name:TRI COUNTY PET LLC
Other - Org Name:PET IMAGING INSTITUTE OF SOUTH FL.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ-DENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-981-6668
Mailing Address - Street 1:1150 N 35TH AVE STE 665
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-5432
Mailing Address - Country:US
Mailing Address - Phone:954-981-6668
Mailing Address - Fax:954-981-5944
Practice Address - Street 1:2122 W. CYPRESS CREEK ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309
Practice Address - Country:US
Practice Address - Phone:954-981-6668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-06
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5507261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003906001Medicaid
FL003906000Medicaid
FLV2440OtherFLORIDA BLUE