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'
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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
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Remit To:
Account:
lnv Date:
iia-iiszoo352e -,^.\lri rsi)or, - t2/ 02 /2022
AA/EEO EmPloYer
PAYMENT DUE UPON RECEIPT