Healthcare Provider Details

I. General information

NPI: 1114002094
Provider Name (Legal Business Name): SOUTH BRANDON IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 W BRANDON BLVD
BRANDON FL
33511-4901
US

IV. Provider business mailing address

737 W BRANDON BLVD
BRANDON FL
33511-4901
US

V. Phone/Fax

Practice location:
  • Phone: 813-657-7575
  • Fax: 813-684-3040
Mailing address:
  • Phone: 813-657-7575
  • Fax: 813-684-3040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LAVELLE HARDIN
Title or Position: ENROLLMENT
Credential:
Phone: 615-344-8203