Provider Demographics
NPI:1801877618
Name:PUYALLUP OPEN IMAGING LLC
Entity type:Organization
Organization Name:PUYALLUP OPEN IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-630-9804
Mailing Address - Street 1:2784 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3159
Mailing Address - Country:US
Mailing Address - Phone:877-630-9804
Mailing Address - Fax:503-586-1300
Practice Address - Street 1:12623 MERIDIAN E
Practice Address - Street 2:STE A1
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3469
Practice Address - Country:US
Practice Address - Phone:253-864-6531
Practice Address - Fax:253-864-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7114465Medicaid
WA7114465Medicaid