Provider Demographics
NPI:1124038732
Name:SPORTS IMAGING CENTERS, LLC
Entity Type:Organization
Organization Name:SPORTS IMAGING CENTERS, LLC
Other - Org Name:WINDSOR IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBY
Authorized Official - Middle Name:YYONNE
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-466-5050
Mailing Address - Street 1:1000 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982
Mailing Address - Country:US
Mailing Address - Phone:772-466-5050
Mailing Address - Fax:772-467-1003
Practice Address - Street 1:1000 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982
Practice Address - Country:US
Practice Address - Phone:772-466-5050
Practice Address - Fax:772-467-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC80312085R0202X
2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001110400Medicaid
FLV1780OtherBC
FLV1780OtherBLUE CROSS BLUE SHEILD