Healthcare Provider Details

I. General information

NPI: 1447654066
Provider Name (Legal Business Name): BOSTON IMAGING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 HARRISON AVE #506
BOSTON MA
02111-1924
US

IV. Provider business mailing address

37 ADELLE DR
DOVER NH
03820-4457
US

V. Phone/Fax

Practice location:
  • Phone: 860-801-0330
  • Fax: 860-415-6388
Mailing address:
  • Phone: 860-801-0330
  • Fax: 860-415-6388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number129878
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number129878
License Number StateMA

VIII. Authorized Official

Name: MS. WENXING FAN
Title or Position: MANAGER
Credential: M.D.
Phone: 860-801-0330