Provider Demographics
NPI:1881865079
Name:DIAGNOSTIC SERVICE CENTER OF NORTH MIAMI BEACH LLC
Entity Type:Organization
Organization Name:DIAGNOSTIC SERVICE CENTER OF NORTH MIAMI BEACH LLC
Other - Org Name:FOUNTAIN IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS DEVELOPMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:TREMBLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-770-4343
Mailing Address - Street 1:88 NE 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3410
Mailing Address - Country:US
Mailing Address - Phone:305-770-4343
Mailing Address - Fax:305-770-4373
Practice Address - Street 1:1 NE 167TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3402
Practice Address - Country:US
Practice Address - Phone:305-770-4343
Practice Address - Fax:305-770-4343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6911261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3305OtherBLUE CROSS BLUE SHIELD
FL64817OtherNEIGHBORHOOD HEALTH PLAN
FL319618OtherAVMED
FLF300153OtherFREEDOM HEALTH
FL=========OtherUNITED HEALTHCARE