Healthcare Provider Details

I. General information

NPI: 1659528511
Provider Name (Legal Business Name): IMAGING CENTER OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 ENTERPRISE WAY
CALDWELL ID
83605-8086
US

IV. Provider business mailing address

PO BOX 4813
BOISE ID
83711-4813
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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:
Phone: 208-455-7482