MEDICARE: PALM BEACH DIAGNOSTICS HOLDING, LLC

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	261QR0200X	Radiology Clinic/Center		FL

General Provider Information

NPI Number	:	1831503804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM BEACH DIAGNOSTICS HOLDING, LLC

Provider Business Mailing Address
First Line	:	607 W DR MARTIN LUTHER KING JR BLVD
Second Line	:	SUITE 103
City	:	TAMPA
State	:	FL
Zip	:	33603-3453
Country	:	US
Telephone Number	:	813-238-3833
Fax Number	:

Provider Business Practice Location Address
First Line	:	4215 BURNS RD
Second Line	:	SUITE 220
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4654
Country	:	US
Telephone Number	:	813-238-3833
Fax Number	:	813-849-6349

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. TIFFANY KEMP
Credential	:
Telephone Number	:	813-325-1389

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/17/2014

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