Provider Demographics
NPI:1346573839
Name:ULTRACARE MOBILE DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:ULTRACARE MOBILE DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:HAZELBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:321-795-7396
Mailing Address - Street 1:4181 IONA ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2222
Mailing Address - Country:US
Mailing Address - Phone:321-795-7396
Mailing Address - Fax:321-225-4936
Practice Address - Street 1:4181 IONA ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2222
Practice Address - Country:US
Practice Address - Phone:321-795-7396
Practice Address - Fax:321-225-4936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL570902471S1302X, 335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL885043603OtherBUSINESS LICENSE #