| Entity Name: | FLORIDA DIAGNOSTIC PORTABLE IMAGING, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 25 Feb 1985 (40 years ago) |
| Document Number: | H44175 |
| FEI/EIN Number | 000000000 |
| Address: | 4110 SKYWAY DR, COCOA, FL, 32927 |
| Mail Address: | 4110 SKYWAY DR, COCOA, FL, 32927 |
| ZIP code: | 32927 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1427051887 | 2005-05-31 | 2008-06-05 | 5201 BABCOCK ST NE, STE 2, PALM BAY, FL, 329054637, US | 5201 BABCOCK ST NE, STE 2, PALM BAY, FL, 329054637, US | |||||||||||||||||||||||||||
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| Phone | +1 321-984-8001 |
| Fax | 3217280523 |
Authorized person
| Name | MR. BRUCE D COTTI |
| Role | OWNER |
| Phone | 3219848001 |
Taxonomy
| Taxonomy Code | 335V00000X - Portable X-ray and/or Other Portable Diagnostic Imaging Supplier |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE SHIELD XRAY |
| Number | W9833 |
| State | FL |
| Issuer | MEDICAID |
| Number | 030398400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| KABBOORD, JOHN J. | Agent | 800 E MERRITT ISLAND CSWY, MERRITT ISLAND, FL, 32952 |
| Name | Role | Address |
|---|---|---|
| COTTI, BRUCE | Director | 997 CANADA ST., NE, PALM BAY, FL |
| CULLEN, JAY | Director | 4110 SKYWAY DR., COCOA, FL |
| PYLES, DONALD | Director | 4225 BURKHOLM RD., MIMS, FL |
| BARR, RICHARD I. | Director | 3660 MIRIAM DR., TITUSVILLE, FL |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| INVOLUNTARILY DISSOLVED | 1988-11-04 | No data | No data |
| REINSTATEMENT | 1987-01-26 | No data | No data |
| INVOLUNTARILY DISSOLVED | 1986-11-14 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
