Provider Demographics
NPI:1336475516
Name:INTERMOUNTAIN NEURODIAGNOSTICS INC
Entity Type:Organization
Organization Name:INTERMOUNTAIN NEURODIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOTTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAFLIN
Authorized Official - Suffix:
Authorized Official - Credentials:REEG/T, CNIM
Authorized Official - Phone:208-528-7566
Mailing Address - Street 1:4596 MCCOWIN LANE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403
Mailing Address - Country:US
Mailing Address - Phone:208-524-8372
Mailing Address - Fax:
Practice Address - Street 1:4596 MCCOWIN LN
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-8350
Practice Address - Country:US
Practice Address - Phone:208-524-8372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty