=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548864333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TITAN MRI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2020
-----------------------------------------------------
Last Update Date | 11/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 SW STONEGATE TER STE 102
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32024-3457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-245-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 NW 75TH ST
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32606-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-672-2246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | JOE BOLTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-672-2246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------