Provider Demographics
NPI:1720382427
Name:IDEAL DIAGNOSTIC CENTER INC
Entity Type:Organization
Organization Name:IDEAL DIAGNOSTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:CIFUENTES BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:305-444-0137
Mailing Address - Street 1:PO BOX 350966
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-0966
Mailing Address - Country:US
Mailing Address - Phone:305-444-0137
Mailing Address - Fax:305-444-0137
Practice Address - Street 1:3623 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2543
Practice Address - Country:US
Practice Address - Phone:305-444-0137
Practice Address - Fax:305-444-0137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 61215261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation