Provider Demographics
NPI:1710605696
Name:TELLICA IMAGING, LLC
Entity Type:Organization
Organization Name:TELLICA IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NANNETTE
Authorized Official - Middle Name:MIGNON
Authorized Official - Last Name:BERENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-507-8002
Mailing Address - Street 1:36 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 W 13290 S
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:801-442-5737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-17
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology