Provider Demographics
NPI:1801090204
Name:IMAGING CENTER OF IDAHO, LLC
Entity type:Organization
Organization Name:IMAGING CENTER OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:F
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:BS, RT, R
Authorized Official - Phone:208-629-6235
Mailing Address - Street 1:4519 ENTERPRISE WAY
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-9999
Mailing Address - Country:US
Mailing Address - Phone:208-455-7482
Mailing Address - Fax:208-455-7538
Practice Address - Street 1:4519 ENTERPRISE WY
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-9999
Practice Address - Country:US
Practice Address - Phone:208-455-7482
Practice Address - Fax:208-455-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone DensitometryGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
No2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammographyGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)