Provider Demographics
NPI:1376711309
Name:WEST BOYNTON BEACH OPEN IMAGING CENTER LLC
Entity Type:Organization
Organization Name:WEST BOYNTON BEACH OPEN IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP IMAGING SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-838-3630
Mailing Address - Street 1:10151 ENTERPRISE CENTER BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3759
Mailing Address - Country:US
Mailing Address - Phone:561-752-5050
Mailing Address - Fax:561-364-5606
Practice Address - Street 1:10151 ENTERPRISE CENTER BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3759
Practice Address - Country:US
Practice Address - Phone:561-752-5050
Practice Address - Fax:561-364-5606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000260600Medicaid
FLV3267OtherBCBS OF FL
FL000260600Medicaid