=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669651469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOCA RATON OPEN IMAGING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2007
-----------------------------------------------------
Last Update Date | 10/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 CLINT MOORE RD SUITE 140
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33487-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-939-0850
-----------------------------------------------------
Fax | 561-939-0899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 MAPLEWOOD DR SUITE 10
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-5849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-741-4330
-----------------------------------------------------
Fax | 561-741-1815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. GARTH LAWSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-838-3630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------