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General NPI Number Information
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NPI Number | 1518727734
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Entity Type | Organization
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Legal Business Name | TELLICA IMAGING, LLC
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Dates
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Enumeration Date | 03/22/2024
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Last Update Date | 08/27/2025
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Provider Practice Location Address
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Address Line | 692 EAST MARKET PLACE DRIVE
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City | SPANISH FORK
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State | UT
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Zip | 84660
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Country | US
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Telephone | 610-772-7252
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Fax |
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Provider Business Mailing Address
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Address Line | 36 S STATE ST
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City | SALT LAKE CITY
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State | UT
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Zip | 84111-1401
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRAD ISAACSON
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Credential |
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Telephone | 151-872-7734
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 293D00000X
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Taxonomy Name | Physiological Laboratory
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License Number |
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License Number State |
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