Provider Demographics
NPI:1407957434
Name:AMBULATORY DIAGNOSTIC CENTER INC
Entity Type:Organization
Organization Name:AMBULATORY DIAGNOSTIC CENTER INC
Other - Org Name:PONCE DE LEON DIAGNOSTIC SERVICES LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-863-8860
Mailing Address - Street 1:747 PONCE DE LEON BLVD
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2049
Mailing Address - Country:US
Mailing Address - Phone:305-446-7893
Mailing Address - Fax:305-442-1183
Practice Address - Street 1:747 PONCE DE LEON BLVD
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2049
Practice Address - Country:US
Practice Address - Phone:305-446-7893
Practice Address - Fax:305-442-1183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058543200Medicaid