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General NPI Number Information
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NPI Number | 1649335373
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Entity Type | Organization
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Legal Business Name | IDAHO ADVANCED IMAGING PA
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Dates
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Enumeration Date | 12/22/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1512 12TH AVE RD
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City | NAMPA
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State | ID
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Zip | 83686-6008
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Country | US
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Telephone | 208-463-5431
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 9649
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City | BOISE
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State | ID
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Zip | 83707-4649
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Country | US
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Telephone | 208-472-8121
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Fax | 208-472-8172
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Authorized Official
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Title or Position | OWNER
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Name | JANICE W BROOKS
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Credential | MD
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Telephone | 208-463-5431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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