Provider Demographics
NPI:1871985853
Name:IDEAL IMAGE
Entity type:Organization
Organization Name:IDEAL IMAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:GAUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:305-507-3461
Mailing Address - Street 1:330 SAN LORENZO AVE
Mailing Address - Street 2:2345
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1846
Mailing Address - Country:US
Mailing Address - Phone:305-507-3461
Mailing Address - Fax:305-774-6624
Practice Address - Street 1:330 SAN LORENZO AVE
Practice Address - Street 2:2345
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1846
Practice Address - Country:US
Practice Address - Phone:305-507-3461
Practice Address - Fax:305-774-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9196713261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service