Provider Demographics
NPI:1316596471
Name:SUMMERLIN IMAGING CENTER LLC
Entity Type:Organization
Organization Name:SUMMERLIN IMAGING CENTER LLC
Other - Org Name:JACKSONVILLE DIAGNOSTIC IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-331-0808
Mailing Address - Street 1:6415 LAKE WORTH RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3009
Mailing Address - Country:US
Mailing Address - Phone:561-331-0808
Mailing Address - Fax:561-237-6034
Practice Address - Street 1:3550 UNIVERSITY BLVD S STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4227
Practice Address - Country:US
Practice Address - Phone:561-331-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty