Provider Demographics
NPI:1538807656
Name:DESTIN REGIONAL IMAGING CENTER LLC
Entity type:Organization
Organization Name:DESTIN REGIONAL IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-278-3556
Mailing Address - Street 1:PO BOX 1977
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1977
Mailing Address - Country:US
Mailing Address - Phone:855-410-3201
Mailing Address - Fax:
Practice Address - Street 1:75 ORIGINS MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WATERSOUND
Practice Address - State:FL
Practice Address - Zip Code:32461-8647
Practice Address - Country:US
Practice Address - Phone:850-278-3556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00871OtherBC OF FLORIDA