Healthcare Provider Details

I. General information

NPI: 1326099201
Provider Name (Legal Business Name): PRESBYTERIAN BREAST CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 LILLINGTON AVENUE
CHARLOTTE NC
28204
US

IV. Provider business mailing address

PO BOX 603543
CHARLOTTE NC
28260-3543
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-5000
  • Fax:
Mailing address:
  • Phone: 678-393-5600
  • Fax: 770-300-9018

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
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateNC

VIII. Authorized Official

Name: GEOFFREY GARDNER
Title or Position: SVP FINANCE AND REVENUE CYCLE
Credential:
Phone: 336-718-2078