Healthcare Provider Details

I. General information

NPI: 1275584179
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: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14215 BALLANTYNE CORPORATE PLACE STE 140
CHARLOTTE NC
28277-3146
US

IV. Provider business mailing address

2085 FRONTIS PLAZA BLVD
WINSTON SALEM NC
27103-5614
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1890
  • Fax:
Mailing address:
  • Phone: 336-277-7226
  • Fax: 336-277-9795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FRED M HARGETT
Title or Position: EVP CFO
Credential:
Phone: 704-384-5184