Healthcare Provider Details

I. General information

NPI: 1396992830
Provider Name (Legal Business Name): EMRAN PARVEEN AND SON'S BREAST CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 09/30/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 BROADBAND DR
MELBOURNE FL
32901-2623
US

IV. Provider business mailing address

PO BOX 33428
INDIALANTIC FL
32903-0428
US

V. Phone/Fax

Practice location:
  • Phone: 321-733-1901
  • Fax: 321-733-0211
Mailing address:
  • Phone: 321-733-1901
  • Fax: 321-733-0211

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: DR. EMRAN RIAZ IMAMI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 321-733-1901