Healthcare Provider Details

I. General information

NPI: 1952180887
Provider Name (Legal Business Name): BOUTIQUE BREAST IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6871 BELFORT OAKS PL
JACKSONVILLE FL
32216-6242
US

IV. Provider business mailing address

823 WATERMAN RD N
JACKSONVILLE FL
32207-5240
US

V. Phone/Fax

Practice location:
  • Phone: 904-553-8806
  • Fax:
Mailing address:
  • Phone: 904-553-8806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN PEARSON PEYTON
Title or Position: MANAGER
Credential: MD
Phone: 904-553-8806