Healthcare Provider Details

I. General information

NPI: 1588634356
Provider Name (Legal Business Name): PORTABLE XRAY OF IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2399 S ORCHARD ST
BOISE ID
83705-3793
US

IV. Provider business mailing address

5538 DUNCAN DR
LAS VEGAS NV
89130-2812
US

V. Phone/Fax

Practice location:
  • Phone: 702-395-5011
  • Fax:
Mailing address:
  • Phone: 702-645-2606
  • Fax: 702-645-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROL TOOMEY
Title or Position: MEMBER
Credential:
Phone: 702-645-2606