Healthcare Provider Details

I. General information

NPI: 1780916262
Provider Name (Legal Business Name): IMAGINE THAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1254 BAYVIEW RD
ATHOL ID
83801-9659
US

IV. Provider business mailing address

1254 BAYVIEW RD
ATHOL ID
83801-9659
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-9318
  • Fax:
Mailing address:
  • Phone: 208-255-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. JEROMY M. SCHEEL
Title or Position: OWNER
Credential: BBA
Phone: 208-255-9318