Provider Demographics
NPI:1760197198
Name:TELLICA IMAGING, LLC
Entity Type:Organization
Organization Name:TELLICA IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAWDREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-718-1642
Mailing Address - Street 1:36 S STATE ST STE 2200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8505 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1644
Practice Address - Country:US
Practice Address - Phone:208-417-5100
Practice Address - Fax:208-417-5105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-19
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty