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HomeMy WebLinkAboutInv# 1155999991 - CONCENTRA MEDICAL CENTERS - 12/14/2022Conceniire Tax ld: i5-2OL4A2B Account: N33-1242003529 lnvoice: 1155999991 Balance: Bill To: city of Dania Beach Attn: Linda Gonzalez 1OO W Dania Beach Blvd Dania, EL 33004-3643 PLEASE INVOICE Remit To: lnvoice Date: Date Printed: Occupational Health Centers of the Southwest, P.A. PO Box 82549 Hapevj-11e, GA 30354-0549 (800) 686-0468 17 / 29 / 2022 - 72/ 02/2022 \2/05/2022$28s.00 Location: City of Dania Beach Attn: Linda Gonzalez 100 W Dania Beach Blvd Dania, EL 33004-3643 RETURN THIS PORTION WITH YOUR REMIfiANCE' ssN / Birth date Charge DescriPtion Charge Amount Pmts / AdjmntsName / PO NumberDate ttr" uot Lowing Services Performed l,auderdale Fitness for DutY PhYs-LvI 3 . Eitness for Duty pf-'V"ituf -f'""tf 133 ' 00 Phys-LvI 2 w/Non Reg UDS 5 Pnl 41.00physical-Lever z 1 .i.rE* 35.OO No-n Requlated UDS 5 Pane-L ztLLJ Phvs-LvI 2 w/Non Reg UDS 5 lll-' I'j'""-ln""t"a u""i"pt"tr 2'12.5* i?:33 PhYsical-LeveL z LL/29/2022 Brown' Rodrick tL/29/2022 Gunson' Patricia LZl02/2022 Rodrj-guez' Ninoska at CMC - MIA Ft xxx-xx- xx/xx/xxxx xxx-xx-0119 xx/xx/xxxx xxx-xx-3812 xx/xx/xxxx Balance Due: $285 ' 00 1,A l{,;Mtu' o. " "j. r* r Ii" a I th c e n t e r s ";';'h; southwest' P'A'we app r e c i u.. y:"" o:ll'.??ll ;.Iil,qli t :::r::H:lt m:.:: =hrrps : / /pavmenc'':;;:";i;"". .:?::i:ar inrormation .madl via "I:*1:"ii'oI;r- ior additioloffice at Boo-bub-uaao page: l/l Remit To: Account: lnv Date: iia-iiszoo352e -,^.\lri rsi)or, - t2/ 02 /2022 AA/EEO EmPloYer PAYMENT DUE UPON RECEIPT