Healthcare Provider Details

I. General information

NPI: 1982670022
Provider Name (Legal Business Name): INSTITUTE OF DIAGNOSTIC IMAGING,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 RACETRACK RD NW
FT WALTON BEACH FL
32547-1556
US

IV. Provider business mailing address

424 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1556
US

V. Phone/Fax

Practice location:
  • Phone: 850-314-7575
  • Fax: 850-314-7494
Mailing address:
  • Phone: 850-314-7575
  • Fax: 850-314-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number602617
License Number StateFL

VIII. Authorized Official

Name: LAURIE BORGSTROM
Title or Position: OFFICE MANAGER
Credential:
Phone: 850-314-7575