Basic Information
| Provider Information | |||||||||
| NPI: | 1811257876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STAND-UP MRI OF LAKELAND, LLC | ||||||||
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| Address1: | 2120 LAKELAND HILLS BLVD | ||||||||
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| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338052906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2012 | ||||||||
| LastUpdateDate: | 05/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | GOODEMOTE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8635770303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
No ID Information.