1689652216 NPI number — BIOPSY DIAGNOSTICS, LLC

Table of content: (NPI 1689652216)

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: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • 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" .

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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