Provider Demographics
NPI:1417953852
Name:WEST FLORIDA PET SERVICES LLC
Entity Type:Organization
Organization Name:WEST FLORIDA PET SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-309-2190
Mailing Address - Street 1:427 SOUTH PARSONS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5980
Mailing Address - Country:US
Mailing Address - Phone:813-315-2080
Mailing Address - Fax:813-315-2090
Practice Address - Street 1:427 SOUTH PARSONS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5980
Practice Address - Country:US
Practice Address - Phone:813-315-2080
Practice Address - Fax:813-315-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3345OtherBCBS OF FL
FLBY687Medicare PIN