Healthcare Provider Details

I. General information

NPI: 1073949723
Provider Name (Legal Business Name): NEURORAD DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 YAMATO RD STE 1100
BOCA RATON FL
33431-4901
US

IV. Provider business mailing address

301 YAMATO RD STE 1100
BOCA RATON FL
33431-4901
US

V. Phone/Fax

Practice location:
  • Phone: 855-200-2632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME30779
License Number StateFL

VIII. Authorized Official

Name: RUSSELL PACKARD
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 855-200-2632