Provider Demographics
NPI:1831534569
Name:LG DIAGNOSTIC, INC
Entity type:Organization
Organization Name:LG DIAGNOSTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURE
Authorized Official - Prefix:
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-267-4414
Mailing Address - Street 1:815 NW 57TH AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2068
Mailing Address - Country:US
Mailing Address - Phone:305-267-4414
Mailing Address - Fax:
Practice Address - Street 1:815 NW 57TH AVE STE 125
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2068
Practice Address - Country:US
Practice Address - Phone:305-267-4414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LG DIAGNOSTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT4229225XP0019X
FLPT15233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty