1689652216 NPI number — BIOPSY DIAGNOSTICS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689652216 NPI number — BIOPSY DIAGNOSTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIOPSY DIAGNOSTICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689652216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11025 RCA CENTER DRIVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-4269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-626-5512
Provider Business Mailing Address Fax Number:
561-626-4530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 RIVERWALK BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-379-2939
Provider Business Practice Location Address Fax Number:
843-379-2949
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VALLADARES
Authorized Official First Name:
DINA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, CREDENTIALING AND PE
Authorized Official Telephone Number:
561-514-5822

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  14814 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 052853 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 00024917 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 33767 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: PFI8422 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 024354700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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