=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144517400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALM BEACH MOBILE SONOGRAPHY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2011
-----------------------------------------------------
Last Update Date | 01/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3205 FLORAL AVE
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33407-4921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-848-6066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3205 FLORAL AVE
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33407-4921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-848-6066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. WILBUR ALAN WATKINS JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-848-6066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------