=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104944297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRADENTON OUTPATIENT FLUOROSCOPIC SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 10/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1471 CADES BAY AVE
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-630-6277
-----------------------------------------------------
Fax | 561-630-6062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1471 CADES BAY AVE
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-630-6277
-----------------------------------------------------
Fax | 561-630-6062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. DONNA M. SCROGGINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-630-6277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------