Healthcare Provider Details

I. General information

NPI: 1023065844
Provider Name (Legal Business Name): POUDRE VALLEY OPEN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E PROSPECT RD
FORT COLLINS CO
80525-9729
US

IV. Provider business mailing address

PO BOX 6102
NOVATO CA
94948-6102
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-0567
  • Fax:
Mailing address:
  • Phone: 415-884-3418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateCO

VIII. Authorized Official

Name: MICHAEL P BELICK
Title or Position: C.E.O.
Credential:
Phone: 415-884-3096