MEDICARE: F B A DIAGNOSTIC CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0206X	Mammography Clinic/Center	HCC6243	FL

General Provider Information

NPI Number	:	1700956042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	F B A DIAGNOSTIC CENTER INC

Provider Business Mailing Address
First Line	:	697 E 9TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-4523
Country	:	US
Telephone Number	:	305-863-3738
Fax Number	:	305-863-3739

Provider Business Practice Location Address
First Line	:	697 E 9TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-4523
Country	:	US
Telephone Number	:	305-863-3738
Fax Number	:	305-863-3739

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BENJAMIN A VALDES
Credential	:
Telephone Number	:	305-863-3738

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	01/07/2008

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