HomeMy WebLinkAboutInv# 1155899783 - CONCENTRA MEDICAL CENTERS - 10/28/2022Concenaira'
Tax ld: 15-20L4828
Account N33-1242003529
lnvoice: 1155899783 Balance:
Bill To: city of Dania Beach
Attn: Linda Gonzalez
100 W Dania Beach Blvd
Dania, EL 33004-3643
PLEASE
INVOIGE
Remit To:
lnvoice Date:
Date Printed:
Occupational Health Centers
of the Southwest, P'A'
PO Box 82549
Hapevi-IIe, GA 30354-0549
(800) 686-0468
LO/ 05/2022 - t0 / 08 / 2022
L0/L0/20225228 .00
Location: citY of Dania Beach
Attn: Linda Gonzalez
100 W Dania Beach Blvd
Dania, FL 33004-3643
PORTION WITH YOUR REMIfiANCE.
Name /
PO Number
RETURN THIS
ssN /
Birth date
Charge
DescriPtion
Charge
Amount
Pmts /
Adjmnts
Date
The Eoll.owi-ng Se::vices Performed at
:_O/05/2022 ShahrYar, MicheIIe M
:rO/08/2A22 Edge, Charles J
Lauderdale
Phys-Lvl 2 w/Non Reg UDS-5 f1}-lloi n"grl.ted UDS 5 Panel 21215x 35'00
;;;"1;;i-Lever 2 41 'oo
Phys-LvI 2 w/Non Reg UDS S-!11-
lloi-n"g,rl-uted UDS 5 Panel 2':.275* 35 ' 00
;;;"r;;i-iever 2 41'oo
CMC - MIA Ft
xxx-xx-2154
xx/xx/xxxx
xxx-xx-5641
xx/xx/xxxx
The Eollowing Services Performed
10/05/2022 Mierez, Ann
at CMC - MIA Plantation
xxx-xx-7836 Phvs-Lvl 2 w/Non Reg UDS 5 Il1-,
xx/xx/xxxx Noi-n"qt-'f uted uDS 5 Panel 2'1215* 35 ' 00
iiv"I.li-r,evel 2 41'oo
Balance Due: S22B .00
tb-
Remit To:
Account:
lnv Date:
Occupational Health Centers
of the Southwest, P'A'
N33-1242003529
to / 05/2022 - 10 / oB /2022
We appreciate your business' You can now pay online at
https://payment".;";;;;'ta'com/' onrine payments must be
made via credit tuia' pf"use contact our Central Business
Office at 800-686-OAAg for additional information'
Page: L/L
AA/EEO EmPloYer PAYMENT DUE UPON RECEIPT
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