Provider Demographics
NPI:1205329620
Name:CENTRAL FLORIDA CARDIOVASCULAR IMAGING CENTER, LLC
Entity type:Organization
Organization Name:CENTRAL FLORIDA CARDIOVASCULAR IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-703-1258
Mailing Address - Street 1:1717 MAYO DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4307
Mailing Address - Country:US
Mailing Address - Phone:352-253-0003
Mailing Address - Fax:352-253-0016
Practice Address - Street 1:1717 MAYO DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4307
Practice Address - Country:US
Practice Address - Phone:352-253-0003
Practice Address - Fax:352-253-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty