Provider Demographics
NPI:1184709701
Name:PROFESSIONAL HEALTH DIAGNOSTICS, INC
Entity type:Organization
Organization Name:PROFESSIONAL HEALTH DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOENAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-441-2262
Mailing Address - Street 1:6527 SW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1843
Mailing Address - Country:US
Mailing Address - Phone:305-441-2262
Mailing Address - Fax:305-441-2292
Practice Address - Street 1:6527 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1843
Practice Address - Country:US
Practice Address - Phone:305-441-2262
Practice Address - Fax:305-441-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCC5108261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5579Medicare ID - Type UnspecifiedIDTF