Provider Demographics
NPI:1750368890
Name:WHITE MOUNTAIN IMAGING, LLC
Entity type:Organization
Organization Name:WHITE MOUNTAIN IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOEFLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-2077
Mailing Address - Street 1:5448 HIGHWAY 260
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5739
Mailing Address - Country:US
Mailing Address - Phone:928-537-2077
Mailing Address - Fax:928-537-5282
Practice Address - Street 1:5448 HIGHWAY 260
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5739
Practice Address - Country:US
Practice Address - Phone:928-537-2077
Practice Address - Fax:928-537-5282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC57242471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ918972Medicaid
AZ103210Medicare PIN