Basic Information
| Provider Information | |||||||||
| NPI: | 1104079821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3704 SE 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339045075 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2727 WINKLER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399393939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2008 | ||||||||
| LastUpdateDate: | 10/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | PACETTI | ||||||||
| AuthorizedOfficialFirstName: | JOANNE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | RADIOGRAPHER | ||||||||
| AuthorizedOfficialTelephone: | 2399393939 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ARRT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | 168043 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QH0100X | 28080 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.