Healthcare Provider Details

I. General information

NPI: 1801090204
Provider Name (Legal Business Name): IMAGING CENTER OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 ENTERPRISE WY
CALDWELL ID
83605-9999
US

IV. Provider business mailing address

4519 ENTERPRISE WAY
CALDWELL ID
83605-9999
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-7482
  • Fax: 208-455-7538
Mailing address:
  • Phone: 208-455-7482
  • Fax: 208-455-7538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY F. CLARK
Title or Position: CEO
Credential: B.S., RT, R
Phone: 208-629-6235