=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255769386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLC DIAGNOSTIC IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2013
-----------------------------------------------------
Last Update Date | 10/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6202 W FREEDOM HILL WAY
-----------------------------------------------------
City | HERRIMAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-6987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-253-6452
-----------------------------------------------------
Fax | 801-253-5114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6202 W FREEDOM HILL WAY
-----------------------------------------------------
City | HERRIMAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-6987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-253-6452
-----------------------------------------------------
Fax | 801-253-5114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MRS. VALERIE LUCKING
-----------------------------------------------------
Credential | RDCS
-----------------------------------------------------
Telephone | 801-253-6452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 774
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------