Provider Demographics
NPI:1811257876
Name:STAND-UP MRI OF LAKELAND, LLC
Entity type:Organization
Organization Name:STAND-UP MRI OF LAKELAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOODEMOTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHD
Authorized Official - Phone:863-577-0303
Mailing Address - Street 1:2120 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2906
Mailing Address - Country:US
Mailing Address - Phone:863-688-2334
Mailing Address - Fax:863-577-0301
Practice Address - Street 1:1121 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4655
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:863-577-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)