Provider Demographics
NPI:1578789525
Name:MOUNTAIN VALLEY IMAGING LLC
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-359-6508
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:450 EAST MAIN
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0031
Mailing Address - Country:US
Mailing Address - Phone:208-359-6508
Mailing Address - Fax:208-356-3066
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2048
Practice Address - Country:US
Practice Address - Phone:208-359-6508
Practice Address - Fax:208-356-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1156471-00Medicaid
ID71910OtherBLUE CROSS
ID71910OtherBLUE CROSS