Provider Demographics
NPI:1497855381
Name:SUMMIT IMAGING LLC
Entity Type:Organization
Organization Name:SUMMIT IMAGING LLC
Other - Org Name:CLOVIS OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-763-6144
Mailing Address - Street 1:821 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4466
Mailing Address - Country:US
Mailing Address - Phone:575-763-6144
Mailing Address - Fax:575-763-6147
Practice Address - Street 1:821 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4466
Practice Address - Country:US
Practice Address - Phone:575-763-6144
Practice Address - Fax:575-763-6147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95687262Medicaid
NM04074975Medicaid
P00182692OtherRR MEDICARE
P00182692OtherRAILROAD MEDICARE