Provider Demographics
NPI:1619446853
Name:MYVY SOUTHWEST IMAGING LLC
Entity type:Organization
Organization Name:MYVY SOUTHWEST IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GENNADIY
Authorized Official - Middle Name:
Authorized Official - Last Name:VERLOKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-932-4565
Mailing Address - Street 1:1160 KANE CONCOURSE STE 402
Mailing Address - Street 2:
Mailing Address - City:BAY HARBOR IS
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1160 KANE CONCOURSE STE 402
Practice Address - Street 2:
Practice Address - City:BAY HARBOR IS
Practice Address - State:FL
Practice Address - Zip Code:33154-2059
Practice Address - Country:US
Practice Address - Phone:646-932-4565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-16
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory