Healthcare Provider Details

I. General information

NPI: 1508875360
Provider Name (Legal Business Name): DIAGNOSTIC IMAGING SERVICE OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 BENCH RD SUITE F
POCATELLO ID
83201-2073
US

IV. Provider business mailing address

1951 BENCH RD SUITE F
POCATELLO ID
83201-2073
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-0977
  • Fax: 208-237-0985
Mailing address:
  • Phone: 208-237-0977
  • Fax: 208-237-0985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES JAY EVERSON
Title or Position: OWNER
Credential: RDMS
Phone: 208-237-0977