=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578789525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN VALLEY IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 05/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 E MAIN ST
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-359-6508
-----------------------------------------------------
Fax | 208-356-3066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31 450 EAST MAIN
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-0031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-359-6508
-----------------------------------------------------
Fax | 208-356-3066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID VICTOR HANSEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-359-6508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------