Provider Demographics
NPI:1942534672
Name:SRA VENTURES, INC.
Entity Type:Organization
Organization Name:SRA VENTURES, INC.
Other - Org Name:WESTCOAST RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-228-6635
Mailing Address - Street 1:501 S LINCOLN AVE
Mailing Address - Street 2:15
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-5945
Mailing Address - Country:US
Mailing Address - Phone:727-446-6760
Mailing Address - Fax:
Practice Address - Street 1:572 OCOEE COMMERCE PARKWAY
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761
Practice Address - Country:US
Practice Address - Phone:407-228-6635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4187OtherMEDICARE PTAN