Provider Demographics
NPI:1124020656
Name:TRI COUNTY PET LLC
Entity type:Organization
Organization Name:TRI COUNTY PET LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ-DENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-981-6668
Mailing Address - Street 1:1150 N 35TH AVE
Mailing Address - Street 2:SUITE 665
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-5424
Mailing Address - Country:US
Mailing Address - Phone:954-981-6668
Mailing Address - Fax:954-981-5944
Practice Address - Street 1:1150 N 35TH AVE
Practice Address - Street 2:SUITE 665
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5424
Practice Address - Country:US
Practice Address - Phone:954-981-6668
Practice Address - Fax:954-981-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5507261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3783BMedicare PIN