Healthcare Provider Details

I. General information

NPI: 1104839737
Provider Name (Legal Business Name): LAKEWOOD RANCH IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 LAKEWOOD RANCH BLVD
BRADENTON FL
34202-5174
US

IV. Provider business mailing address

PO BOX 409956
ATLANTA GA
30384-9956
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-3050
  • Fax:
Mailing address:
  • Phone: 941-782-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DIANE BYNUM
Title or Position: DIRECTOR
Credential:
Phone: 941-782-3050