Provider Demographics
NPI:1700056009
Name:ACTIVE DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:ACTIVE DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:813-348-0049
Mailing Address - Street 1:PO BOX 320905
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33679-2905
Mailing Address - Country:US
Mailing Address - Phone:813-348-0049
Mailing Address - Fax:
Practice Address - Street 1:3110 W GRAY ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1516
Practice Address - Country:US
Practice Address - Phone:813-348-0049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL080000170782471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty