Provider Demographics
NPI:1255573002
Name:PRUDENTIAL DIAGNOSTIC CENTER CORP.
Entity type:Organization
Organization Name:PRUDENTIAL DIAGNOSTIC CENTER CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-827-9140
Mailing Address - Street 1:900 W 49TH ST
Mailing Address - Street 2:308
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3402
Mailing Address - Country:US
Mailing Address - Phone:305-827-9140
Mailing Address - Fax:305-827-9143
Practice Address - Street 1:900 W 49TH ST
Practice Address - Street 2:308
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3402
Practice Address - Country:US
Practice Address - Phone:305-827-9140
Practice Address - Fax:305-827-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7306261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service