Healthcare Provider Details

I. General information

NPI: 1992729487
Provider Name (Legal Business Name): MIRAGE IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 E 23RD AVE
HUTCHINSON KS
67502-1106
US

IV. Provider business mailing address

1818 E 23RD AVE
HUTCHINSON KS
67502-1106
US

V. Phone/Fax

Practice location:
  • Phone: 620-663-4800
  • Fax: 620-663-4803
Mailing address:
  • Phone: 620-663-4800
  • Fax: 620-663-4803

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: GORDON FUNK
Title or Position: CEO
Credential:
Phone: 620-663-4800