Provider Demographics
NPI:1558375469
Name:MONUMENT-9A IMAGING & DIAGNOSTIC CENTER L L C
Entity Type:Organization
Organization Name:MONUMENT-9A IMAGING & DIAGNOSTIC CENTER L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LUIS-JORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-855-0700
Mailing Address - Street 1:1201 MONUMENT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6494
Mailing Address - Country:US
Mailing Address - Phone:904-855-0700
Mailing Address - Fax:904-855-0739
Practice Address - Street 1:1201 MONUMENT RD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6494
Practice Address - Country:US
Practice Address - Phone:904-855-0700
Practice Address - Fax:904-855-0739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5351261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5132Medicare ID - Type Unspecified