Healthcare Provider Details

I. General information

NPI: 1104944297
Provider Name (Legal Business Name): BRADENTON OUTPATIENT FLUOROSCOPIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 10/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 CADES BAY AVE
JUPITER FL
33458-5301
US

IV. Provider business mailing address

1471 CADES BAY AVE
JUPITER FL
33458-5301
US

V. Phone/Fax

Practice location:
  • Phone: 561-630-6277
  • Fax: 561-630-6062
Mailing address:
  • Phone: 561-630-6277
  • Fax: 561-630-6062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DONNA M. SCROGGINS
Title or Position: MANAGER
Credential:
Phone: 561-630-6277