Provider Demographics
NPI:1447654066
Name:BOSTON IMAGING CENTER LLC
Entity type:Organization
Organization Name:BOSTON IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENXING
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-801-0330
Mailing Address - Street 1:37 ADELLE DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-4457
Mailing Address - Country:US
Mailing Address - Phone:860-801-0330
Mailing Address - Fax:860-415-6388
Practice Address - Street 1:65 HARRISON AVE
Practice Address - Street 2:#506
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1924
Practice Address - Country:US
Practice Address - Phone:860-801-0330
Practice Address - Fax:860-415-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA129878261QR0200X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile