Healthcare Provider Details

I. General information

NPI: 1457302341
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: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 RANDOLPH RD
CHARLOTTE NC
28211-1021
US

IV. Provider business mailing address

2085 FRONTIS PLAZA BLVD
WINSTON-SALEM NC
27103-5614
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-4000
  • 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