Provider Demographics
NPI:1508573239
Name:BROADER MRI OF BREVARD COUNTY
Entity Type:Organization
Organization Name:BROADER MRI OF BREVARD COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-241-3627
Mailing Address - Street 1:1930 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-4046
Mailing Address - Country:US
Mailing Address - Phone:321-241-3627
Mailing Address - Fax:305-418-7498
Practice Address - Street 1:1930 DAIRY RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4046
Practice Address - Country:US
Practice Address - Phone:321-241-3627
Practice Address - Fax:305-418-7498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty