Provider Demographics
NPI:1598766826
Name:CENTRAL MONTANA IMAGING LLC
Entity Type:Organization
Organization Name:CENTRAL MONTANA IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:POULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-799-5880
Mailing Address - Street 1:1417 9TH ST S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4509
Mailing Address - Country:US
Mailing Address - Phone:406-216-0040
Mailing Address - Fax:406-216-0041
Practice Address - Street 1:1417 9TH ST S
Practice Address - Street 2:SUITE 102
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4509
Practice Address - Country:US
Practice Address - Phone:406-216-0040
Practice Address - Fax:406-216-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9758261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0760058Medicaid
MT0760058Medicaid