Provider Demographics
NPI:1558348680
Name:PRESGAR IMAGING OF ROCKLEDGE LLC
Entity Type:Organization
Organization Name:PRESGAR IMAGING OF ROCKLEDGE LLC
Other - Org Name:SOUTH BREVARD IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-323-2594
Mailing Address - Street 1:23110 STATE RD 54
Mailing Address - Street 2:PMB 292
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2921
Mailing Address - Country:US
Mailing Address - Phone:352-578-2055
Mailing Address - Fax:813-971-0818
Practice Address - Street 1:1327 OAK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3110
Practice Address - Country:US
Practice Address - Phone:321-729-1449
Practice Address - Fax:321-722-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC4831261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257947200Medicaid