Provider Demographics
NPI:1083802870
Name:WEST DIAGNOSTIC MEDICAL IMAGING INC
Entity Type:Organization
Organization Name:WEST DIAGNOSTIC MEDICAL IMAGING INC
Other - Org Name:WEST DIAGNOSTIC MEDICAL IMAGING INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOLANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-636-3406
Mailing Address - Street 1:6700 N ANDREWS AVE
Mailing Address - Street 2:109
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-2165
Mailing Address - Country:US
Mailing Address - Phone:954-636-3406
Mailing Address - Fax:954-636-5428
Practice Address - Street 1:2170 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1876
Practice Address - Country:US
Practice Address - Phone:186-659-5529
Practice Address - Fax:954-636-5428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2778548Medicaid