Organization
SUMMERLIN IMAGING CENTER LLC
Active
Other names
Park Avenue Imaging
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRADFORD PETERS (CFO)
(561) 331-0808
Entity
Organization
Contact information
Practice address
2128 PARK AVE, ORANGE PARK, FL 32073
(904) 375-8884
(904) 375-8887
Mailing address
6415 LAKE WORTH RD STE 102, GREENACRES, FL 33463-3009
(561) 331-0808
(561) 237-6034
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
HCC10650
AHCC LICENSE
FL
Enumeration date
09/14/2016
Last updated
08/25/2020
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