Provider Demographics
NPI:1477721405
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:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
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:561-346-5606
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:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3267OtherBCBS
FL000260600Medicaid