Provider Demographics
NPI:1710145644
Name:QUALITY MEDICAL IMAGING OF UTAH, INC
Entity Type:Organization
Organization Name:QUALITY MEDICAL IMAGING OF UTAH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:C
Authorized Official - Last Name:FASELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-839-1133
Mailing Address - Street 1:2490 PROFESSIONAL CT STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0835
Mailing Address - Country:US
Mailing Address - Phone:702-839-1133
Mailing Address - Fax:866-274-0710
Practice Address - Street 1:1564 N OVERLAND TRAILS DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-2417
Practice Address - Country:US
Practice Address - Phone:702-839-1133
Practice Address - Fax:702-851-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63916660161335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1104823368Medicaid
UT000060419Medicare PIN