Healthcare Provider Details

I. General information

NPI: 1558337766
Provider Name (Legal Business Name): BREAST CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 MAR WALT DR
FT WALTON BEACH FL
32547-6706
US

IV. Provider business mailing address

918 MAR WALT DR
FT WALTON BEACH FL
32547-6706
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-2006
  • Fax:
Mailing address:
  • Phone: 850-863-2006
  • Fax:

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: SANDRA LEE HANSON
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 850-863-2006