Provider Demographics
NPI:1952353591
Name:PUEBLO MEDICAL IMAGING, LLC
Entity Type:Organization
Organization Name:PUEBLO MEDICAL IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-477-0772
Mailing Address - Street 1:PO BOX 30077
Mailing Address - Street 2:DEPT 306
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0077
Mailing Address - Country:US
Mailing Address - Phone:702-228-0031
Mailing Address - Fax:
Practice Address - Street 1:5495 S RAINBOW BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1872
Practice Address - Country:US
Practice Address - Phone:702-228-0031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500056Medicaid
NVNV1651OtherBCBS OF NV
NVNV1651OtherBCBS OF NV
NVVWCHKBMedicare PIN