MEDICARE: WHITE MOUNTAIN IMAGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471M1202X	Magnetic Resonance Imaging Radiologic Technologist	OTC5724	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750368890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE MOUNTAIN IMAGING, LLC

Provider Business Mailing Address
First Line	:	5448 HIGHWAY 260
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5739
Country	:	US
Telephone Number	:	928-537-2077
Fax Number	:	928-537-5282

Provider Business Practice Location Address
First Line	:	5448 HIGHWAY 260
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5739
Country	:	US
Telephone Number	:	928-537-2077
Fax Number	:	928-537-5282

Authorized Official
Title or Position	:	BOARD MEMBER
Name	:	BRIAN HOEFLE
Credential	:
Telephone Number	:	928-537-2077

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	08/22/2020

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