Provider Demographics
NPI:1053534081
Name:TREASURE COAST DIAGNOSTICS LLC
Entity type:Organization
Organization Name:TREASURE COAST DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALASANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-335-1122
Mailing Address - Street 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:C209
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7553
Mailing Address - Country:US
Mailing Address - Phone:772-335-1122
Mailing Address - Fax:772-335-0023
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:C209
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-335-1122
Practice Address - Fax:772-335-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL117-303-05-1010575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID
FL=========OtherTAX ID