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HomeMy WebLinkAboutInv# 1155826758 - CONCENTRA MEDICAL CENTERS - 09/12/2022Concen{ira Tax ld: is-2oL4B2B Account: N33-1242003529 lnvoice: 1155826758 Balance: $302.00 Bill To: City of Dania Beach Attn: Linda Gonzalez 100 W Dania Beach Blvd Dania, EL 33004-3643 INVOICE lv I 20t A. 05 02 ,l rh P. 54- 5/2 (rln )nters )49 z2 Remit To: lnvoice Date: Date Printed: Occupatj-onal He of the Southwes PO Box 82549 Hapeville, GA 3 (B0o) 686-0468 0B/22/2022 - 0B 08/29/2022 aI 03 /2 Name / PO Number PLEASE RETURN THIS PORTION WITH YOUR REMITTANCE. SSN / Charge Birth date DescriPtion Location: City of Dania Beach Attn: Linda Gonzalez 100 W Dania Beach Blvd Dani-a, EL 33004-3643 Charge Amount Pmts / Adjmnts Date The Fo'l lowing Services Performed OB/25/2022 HenleY, Mokieta L The Following Services Performed 0B/22/2022 C1ark, AshIeY The FoIlowing Services Performed 08/22/2022 Colfins, Roger J 0B/24/2022 Sanchez, Nicholas at CMC - MIA CYPress Creek xXx-XX-2570 DOT Phys PrePl w/Quest-Reg UDS C xx/xx/xxxx DoT Physical PrePlacement at CMC - MIA Golden Glades xxx-xx- Phys-LvI 2 w/Non Reg UDS 5 Pnl xxlxxlxxxx Non Regulated UDS 5 Panel 21275* Physical-Level 2 at CMC - MIA Ft Lauderdale XXX-XX-1963 Injury Care w/Non Reg UDS xx/Xx/XxXX Non Reg UDS 5 PaneL Post xxx-Xx-5389 Phys-LvI 2 w/Non Reg UDSxxlxx/xxxx I;;=l:3liili3ru3' 5 Panel 115.00 35.00 35.00 41.00 Balance Due: $302.00 35.00 41.00 5 Pnl Acciden 5 PnI 2'7 275* Occupat.ional Health Centers Remit To: of tiLe SourhwesL, p . A. Account: N33-1242003529 lnv Date: oB/22/2022 - aB/25/2022 We appreciate your business. You can now pay onfine at httpi-: /,/paymenLs.concentra.com/. online payments must be made via- ciedi-t card. PleaSe contact our Central Business office at 800-686-0468 for additional information' AAIEEO Employer PAYMENT DUE UPON RECEIPT Page: 7/ L