HomeMy WebLinkAboutInv# PC - 3503 - CONCENTRA MEDICAL CENTERS - 03/31/2022Concentra·
Tax Id: 75-2014828
Account N33-1242003529
INVOICE
Remit To:
Invoice Date:
Occupational Health Centers of the Southwest, P.A. PO Box 82549 Hapeville, GA 30354-0549 (800)686-0468
Invoice: 1155401976 Balance: $265. oo Date Printed: 01/10/2022 -01/12/202203/22/2022
Bill To: City of Dania Beach Attn: Linda Gonzalez 100 W Dania Beach Blvd Dania, FL 33004-3643
Bl Location: City of Dania Beach Attn: Linda Gonzalez 100 W Dania Beach Blvd Dania, FL 33004-3643
PLEASE RETURN THIS PORTION WITH YOUR REMITTANCE.
Name/
Date PO Number
SSN / Charge
Birth date Description
Charge
Amount
Pmts /
Adjmnts
The Foll_Q__wing_ Services Performed at CMC -MIA West Palm Beach
01/12/2022 Browne, Johnathan XXX-XX-5295XX/XX/XXXX DOT Phys PrePl w/Quest-Reg UDS C DOT Physical PrePlacement 115. 00
The Following Services Performed at CMC -MIA Ft Lauderdale
01/10/2022 Sanchez, Nicholas XXX-XX-5389XX/XX/XXXX Injury Care w/Non Reg UDS 5 Pnl Non RegUDS 5 Panel Post Accident 35.00
The Following Services Performed at CMC -MIA Commercial Blvd
01/12/2022 Sanabria, David XXX-XX-5008XX/XX/XXXX DOT Phys PrePl w/Quest-Reg UDS C DOT Physical PrePlacement
Remit To:
Account
Inv Date:
Occupational Health Centers of the Southwest, P.A. N33-1242003529 01/10/2022 -01/12/2022
115. 00
Balance Due: $265.00
We appreciate your business. For your convenience we accept all major credit cards. Please reference the invoice number when remitting payment. Please contact our Central Business Office at 800-686-0468 for additional information.
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AA/EEO Employer PAYMENT DUE UPON RECEIPT