Provider Demographics
NPI:1316003726
Name:ADVANCED OPEN IMAGING BOISE LLC
Entity Type:Organization
Organization Name:ADVANCED OPEN IMAGING BOISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-771-8161
Mailing Address - Street 1:PO BOX 1355
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98046-1355
Mailing Address - Country:US
Mailing Address - Phone:425-771-8161
Mailing Address - Fax:425-771-7929
Practice Address - Street 1:3581 EAST OVERLAND RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-846-7494
Practice Address - Fax:208-846-7496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00010146760OtherREGENCE
ID8J133OtherBLUE CROSS
ID1376586Medicare ID - Type Unspecified