Healthcare Provider Details

I. General information

NPI: 1376240101
Provider Name (Legal Business Name): BROADER MRI OF FT PIERCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 PETERS RD #37
FT.PIERCE FL
34948
US

IV. Provider business mailing address

BROADER MRI OF FT PIERCE, LLC 4224 HOLLYWOOD BLVD
HOLLYWOOD FL
33021
US

V. Phone/Fax

Practice location:
  • Phone: 954-966-3600
  • Fax: 954-967-1962
Mailing address:
  • Phone: 954-966-3600
  • Fax: 954-967-1962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ANGEL L SOTO
Title or Position: OWNER, PRESIDENT
Credential:
Phone: 954-966-3600