Healthcare Provider Details

I. General information

NPI: 1225592041
Provider Name (Legal Business Name): CENTRAL FLORIDA RADIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STANDUP MRI OF BREVRD 6023 FARCENDA PLACE - SUITE 101
MELBOURNE FL
32940-7340
US

IV. Provider business mailing address

PO BOX 411145
MELBOURNE FL
32941-1145
US

V. Phone/Fax

Practice location:
  • Phone: 321-409-9990
  • Fax:
Mailing address:
  • Phone: 321-831-1111
  • Fax: 321-831-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA FAUCETT
Title or Position: MANGER
Credential:
Phone: 321-409-9990