Provider Demographics
NPI:1033171186
Name:FLAGLER DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:FLAGLER DIAGNOSTIC IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRETHEWAY
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS, CHBME
Authorized Official - Phone:405-858-2350
Mailing Address - Street 1:2224 NW 50TH ST
Mailing Address - Street 2:SUITE 276W
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8046
Mailing Address - Country:US
Mailing Address - Phone:405-858-2350
Mailing Address - Fax:405-858-2365
Practice Address - Street 1:10 B FLORIDA PARK DRIVE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32135
Practice Address - Country:US
Practice Address - Phone:386-445-3355
Practice Address - Fax:386-445-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
U 6991Medicare ID - Type Unspecified