Provider Demographics
NPI:1780828814
Name:SOUTHEASTERN IMAGING ASSOCIATES INC
Entity Type:Organization
Organization Name:SOUTHEASTERN IMAGING ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS, RDCS, RVT
Authorized Official - Phone:954-325-3911
Mailing Address - Street 1:8461 LAKE WORTH RD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2474
Mailing Address - Country:US
Mailing Address - Phone:561-422-3372
Mailing Address - Fax:561-422-3377
Practice Address - Street 1:8461 LAKE WORTH RD
Practice Address - Street 2:SUITE 235
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2474
Practice Address - Country:US
Practice Address - Phone:561-422-3372
Practice Address - Fax:561-422-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8538261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEJ901Medicare UPIN