Provider Demographics
NPI:1609156231
Name:EXECUTIVE DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:EXECUTIVE DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LEIDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:305-994-7343
Mailing Address - Street 1:5211 NW 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4715
Mailing Address - Country:US
Mailing Address - Phone:305-994-7343
Mailing Address - Fax:305-994-7346
Practice Address - Street 1:5211 NW 79TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-4715
Practice Address - Country:US
Practice Address - Phone:305-994-7343
Practice Address - Fax:305-994-7346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCRT 77803OtherCERTIFIED RADIOLOGY TECHNICIAN
FLHCC 9220OtherFLORIDA HEALTH DEPARTMENT