Healthcare Provider Details

I. General information

NPI: 1427574987
Provider Name (Legal Business Name): TETON SPORTS & SPINE IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 SCOTT LN STE 110
JACKSON WY
83001-8060
US

IV. Provider business mailing address

PO BOX 736
WHEAT RIDGE CO
80034-0736
US

V. Phone/Fax

Practice location:
  • Phone: 307-201-5380
  • Fax: 307-201-5202
Mailing address:
  • Phone: 307-218-8225
  • Fax: 307-218-8226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAUN ANDRIKOPOULOS
Title or Position: MANAGER/PARTNER
Credential:
Phone: 307-201-5380