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General NPI Number Information
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NPI Number | 1619920642
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Entity Type | Organization
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Legal Business Name | FORT WALTON DIAGNOSTIC IMAGING CENTER LLC
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Dates
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Enumeration Date | 05/19/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1112 HOSPITAL RD SUITE C
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6742
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Country | US
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Telephone | 850-862-7070
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Fax | 850-862-0900
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Provider Business Mailing Address
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Address Line | 1112 HOSPITAL RD SUITE C
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6742
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Country | US
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Telephone | 850-862-7070
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Fax | 850-862-0900
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Authorized Official
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Title or Position | MEMBER
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Name | GARY MCMICHAEL
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Credential |
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Telephone | 850-862-7070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | HCC4489
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number | HCC4489
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License Number State | FL
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