Healthcare Provider Details

I. General information

NPI: 1902848591
Provider Name (Legal Business Name): STANDUP MRI OF BOISE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2082 S EAGLE RD
MERIDIAN ID
83642-6707
US

IV. Provider business mailing address

PO BOX 90875
SAN BERNARDINO CA
92427-1875
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-8745
  • Fax: 208-884-8746
Mailing address:
  • Phone: 909-887-8788
  • Fax: 909-887-6345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PETER SOLODKO
Title or Position: CEO
Credential:
Phone: 909-887-8788