Provider Demographics
NPI:1215921820
Name:SANTA CLARA DIAGNOSTIC CENTER INC
Entity type:Organization
Organization Name:SANTA CLARA DIAGNOSTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-498-5658
Mailing Address - Street 1:1275 W 47TH PL
Mailing Address - Street 2:416
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3394
Mailing Address - Country:US
Mailing Address - Phone:305-828-1749
Mailing Address - Fax:305-828-1022
Practice Address - Street 1:1275 W 47TH PL
Practice Address - Street 2:416
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3394
Practice Address - Country:US
Practice Address - Phone:305-828-1749
Practice Address - Fax:305-828-1022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5308Medicare ID - Type UnspecifiedMEDICARE B