Provider Demographics
NPI:1235770686
Name:CLERMONT RADIOLOGY LLC
Entity Type:Organization
Organization Name:CLERMONT RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/COMPLIANCE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-241-6100
Mailing Address - Street 1:PO BOX 593869
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32859-3869
Mailing Address - Country:US
Mailing Address - Phone:352-241-6100
Mailing Address - Fax:352-241-6101
Practice Address - Street 1:18 NE 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6658
Practice Address - Country:US
Practice Address - Phone:352-241-6100
Practice Address - Fax:352-241-6101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLERMONT RADIOLOGY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology