Provider Demographics
NPI:1104079821
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOGRAPHER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PACETTI
Authorized Official - Suffix:
Authorized Official - Credentials:ARRT
Authorized Official - Phone:239-939-3939
Mailing Address - Street 1:3704 SE 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2727 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9358
Practice Address - Country:US
Practice Address - Phone:239-939-3939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-25
Last Update Date:2008-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL168043261QR0206X
FL28080261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography