Healthcare Provider Details

I. General information

NPI: 1235313057
Provider Name (Legal Business Name): SUGAR MILL DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

IV. Provider business mailing address

8303 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

V. Phone/Fax

Practice location:
  • Phone: 352-628-9900
  • Fax: 352-628-9700
Mailing address:
  • Phone: 352-628-9900
  • Fax: 352-628-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberME84779
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberN/A
License Number StateFL

VIII. Authorized Official

Name: DR. MICHAEL KEITH HERRON
Title or Position: OWNER
Credential: M.D.
Phone: 352-795-6909