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General NPI Number Information
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NPI Number | 1760197198
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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 | 01/19/2023
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Last Update Date | 11/20/2023
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Provider Practice Location Address
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Address Line | 8505 W OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83709-1644
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Country | US
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Telephone | 208-417-5100
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Fax | 208-417-5105
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Provider Business Mailing Address
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Address Line | 36 S STATE ST STE 2200
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City | SALT LAKE CITY
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State | UT
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Zip | 84111-1470
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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 | CFO
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Name | MARK L VAWDREY
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Credential |
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Telephone | 801-718-1642
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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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Taxonomy #2
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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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