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General NPI Number Information
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NPI Number | 1952180887
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Entity Type | Organization
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Legal Business Name | BOUTIQUE BREAST IMAGING, LLC
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Dates
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Enumeration Date | 09/28/2023
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Last Update Date | 10/02/2023
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Provider Practice Location Address
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Address Line | 6871 BELFORT OAKS PL
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City | JACKSONVILLE
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State | FL
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Zip | 32216-6242
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Country | US
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Telephone | 904-553-8806
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Fax |
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Provider Business Mailing Address
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Address Line | 823 WATERMAN RD N
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City | JACKSONVILLE
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State | FL
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Zip | 32207-5240
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Country | US
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Telephone | 904-553-8806
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | KATHRYN PEARSON PEYTON
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Credential | MD
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Telephone | 904-553-8806
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0206X
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Taxonomy Name | Mammography Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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