Healthcare Provider Details

I. General information

NPI: 1619258464
Provider Name (Legal Business Name): PRECISION LITHOTRIPSY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 N US HIGHWAY 1
COCOA FL
32926-8724
US

IV. Provider business mailing address

PO BOX 237592
COCOA FL
32923-7592
US

V. Phone/Fax

Practice location:
  • Phone: 321-636-0535
  • Fax: 321-636-1975
Mailing address:
  • Phone: 321-636-0535
  • Fax: 321-636-1975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. SCOTT MASON BAUGHAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 321-403-4078