Provider Demographics
NPI:1073978607
Name:IDEAL IMAGE
Entity Type:Organization
Organization Name:IDEAL IMAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ATALIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-748-1527
Mailing Address - Street 1:17504 PRESERVE WALK LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3243
Mailing Address - Country:US
Mailing Address - Phone:813-549-2299
Mailing Address - Fax:
Practice Address - Street 1:17504 PRESERVE WALK LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3243
Practice Address - Country:US
Practice Address - Phone:813-549-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-26
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9294421251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care