Healthcare Provider Details

I. General information

NPI: 1144802802
Provider Name (Legal Business Name): TELLICA IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 03/22/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 CHAMBERS ST
OGDEN UT
84403-5181
US

IV. Provider business mailing address

36 S STATE ST
SALT LAKE CITY UT
84111-1401
US

V. Phone/Fax

Practice location:
  • Phone: 801-442-5737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRAD ISAACSON
Title or Position: PRESIDENT
Credential: PHD
Phone: 801-442-5737