Provider Demographics
NPI:1801064662
Name:MIDVALLEY IMAGING CENTER LLC
Entity type:Organization
Organization Name:MIDVALLEY IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBENALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-544-1382
Mailing Address - Street 1:1450 E VALLEY RD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8352
Mailing Address - Country:US
Mailing Address - Phone:970-927-8611
Mailing Address - Fax:970-927-8633
Practice Address - Street 1:1460 E VALLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8412
Practice Address - Country:US
Practice Address - Phone:970-544-1551
Practice Address - Fax:970-544-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4270Medicaid