Healthcare Provider Details

I. General information

NPI: 1750368890
Provider Name (Legal Business Name): WHITE MOUNTAIN IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5448 HIGHWAY 260
LAKESIDE AZ
85929-5739
US

IV. Provider business mailing address

5448 HIGHWAY 260
LAKESIDE AZ
85929-5739
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-2077
  • Fax: 928-537-5282
Mailing address:
  • Phone: 928-537-2077
  • Fax: 928-537-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License NumberOTC5724
License Number StateAZ

VIII. Authorized Official

Name: BRIAN HOEFLE
Title or Position: BOARD MEMBER
Credential:
Phone: 928-537-2077