Healthcare Provider Details

I. General information

NPI: 1689652216
Provider Name (Legal Business Name): BIOPSY DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 RIVERWALK BLVD SUITE A
RIDGELAND SC
29936
US

IV. Provider business mailing address

11025 RCA CENTER DRIVE SUITE 300
PALM BEACH GARDENS FL
33410-4269
US

V. Phone/Fax

Practice location:
  • Phone: 843-379-2939
  • Fax: 843-379-2949
Mailing address:
  • Phone: 561-626-5512
  • Fax: 561-626-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14814
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number052853
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number00024917
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number33767
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberPFI8422
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DINA VALLADARES
Title or Position: DIRECTOR, CREDENTIALING AND PE
Credential:
Phone: 561-514-5822