Provider Demographics
NPI:1619370814
Name:INTERMOUNTAIN NEUROVISION
Entity Type:Organization
Organization Name:INTERMOUNTAIN NEUROVISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TATOMIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-866-7399
Mailing Address - Street 1:30251 GOLDEN LANTERN
Mailing Address - Street 2:SUITE E 577
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5993
Mailing Address - Country:US
Mailing Address - Phone:877-446-4945
Mailing Address - Fax:
Practice Address - Street 1:30251 GOLDEN LANTERN
Practice Address - Street 2:SUITE E 577
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5993
Practice Address - Country:US
Practice Address - Phone:877-446-4945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty