Healthcare Provider Details

I. General information

NPI: 1952353591
Provider Name (Legal Business Name): PUEBLO MEDICAL IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5495 S RAINBOW BLVD STE 101
LAS VEGAS NV
89118-1872
US

IV. Provider business mailing address

PO BOX 30077 DEPT 306
SALT LAKE CITY UT
84130-0077
US

V. Phone/Fax

Practice location:
  • Phone: 702-228-0031
  • Fax:
Mailing address:
  • Phone: 702-228-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICAH K NIELSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 702-477-0772