Healthcare Provider Details

I. General information

NPI: 1215887401
Provider Name (Legal Business Name): TELLICA IMAGING - WASHINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2026
Last Update Date: 01/29/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 EAST MAIN STREET
AUBURN WA
98002
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 253-204-2530
  • Fax: 253-617-1296
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRAD ISAACSON
Title or Position: PRESIDENT
Credential:
Phone: 801-442-6000