HomeMy WebLinkAboutInv# 1156358054 - CONCENTRA MEDICAL CENTERS - 06/26/2023Concenttre
INVOICE
Occupational Health Centers
Remit TO: of the Southwest, p.A.
PO Box 82549
Hapeville, GA 30354-0549
Tax ld: 75-2ot4B2B (Bbo) 686-0468Account N33-1242003s29 lnvoice Date: 06/20/2023 - 06/23/2023
lnvoice: 1156358054 Balance: S22B.Oo Date Printed: 06/26/2023
Bill To: Ciry of Dania Beach
Attn: Linda Gonzal-ez
100 W Dania Beach BLvd
Dania, EL 33004-3643
Name /
Date PO Number
Location: Clty of Dania Beach
Attn: Llnda Gonzalez
100 W Dani-a Beach Blvd
Dania, FL 33004-3643
PLEASE RETURN THIS PORTION WITH YOUR REMITTANCE.
SSN /
Birth date
Charge
Description
Charge Pmts /Amount Adjmnts
The Eollowing Services Performed at CMC - MIA Golden Glades
06/23/2023 Wi1liams, Leroy XXX-XX-2811 Phys w/Non Reg UDS 5 Pn1 & HPE
PrePI
The Eollowing Servi-ces Performed at CMC - MIA Ft Lauderdafe
06/20/2023 Ozaydin, Dincer xxx-Xx-8258 Non Reg UDS 5 Pn1 & BAT
PreP]xxlxx/xxxx Breath Alcoho1 Test
XX/XX/XXXK Non Reg UDS 21208 - I Panel 89.00
Physical Exam Concentra Standard 44.00
57.00
Non Reg UDS 21215 - 6 Panel 38.00
Balance Due: 5228 ,00
w
Occupational Health CentersRemitTo: of ti-re Southwest, P.A. we appreciate your business. you can now pay onfj-ne atAccount: N33-1242003529 t-,ttpl,//payments.concentra.com/. onrine piyments must belnv Date: 06/20/2023 - 06/23/2023 made via credit card. Please contact our centraf Business
office at 800-686-0468 for additionaf information.
Paqe: l/ 7
AAIEEOEMPIOYET PAYMENT DUE UPON RECEIPT
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