Provider Demographics
NPI:1609879634
Name:OPEN MRI OF BOISE, L.LC.
Entity Type:Organization
Organization Name:OPEN MRI OF BOISE, L.LC.
Other - Org Name:NYDIC OPEN MRI OF AMERICA-BOISE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUCHWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-573-8080
Mailing Address - Street 1:100 PARAGON DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1718
Mailing Address - Country:US
Mailing Address - Phone:201-573-8080
Mailing Address - Fax:201-505-8905
Practice Address - Street 1:7979 W RIFLEMAN ST
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:208-375-6133
Practice Address - Fax:208-375-6461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1377646Medicare ID - Type UnspecifiedMCR GROUP PROVIDER NUMBER