Healthcare Provider Details

I. General information

NPI: 1760435267
Provider Name (Legal Business Name): FT WALTON OPEN MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 JEFFERSON ST SUITE E
MARIANNA FL
32446-2339
US

IV. Provider business mailing address

3015 JEFFERSON ST SUITE E
MARIANNA FL
32446-2339
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-2496
  • Fax: 850-526-3853
Mailing address:
  • Phone: 850-526-2496
  • Fax: 850-526-3853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License NumberHCC4660
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberHCC4660
License Number StateFL

VIII. Authorized Official

Name: MR. KEITH FREUDENBERGER
Title or Position: MANAGER MEMBER
Credential:
Phone: 850-862-7070