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Organization
TELLICA IMAGING, LLC
Active
Organization
TELLICA IMAGING, LLC
Active
Parent organization
INTERMOUNTAIN HEALTHCARE
Organization subpart
Yes
Provider details
NPI number
Legal business name
INTERMOUNTAIN HEALTHCARE
Authorized official
MARK L VAWDREY (CFO)
(801) 718-1642
Entity
Organization
Contact information
Practice address
8505 W OVERLAND RD, BOISE, ID 83709-1644
(208) 417-5100
(208) 417-5105
Mailing address
36 S STATE ST STE 2200, SALT LAKE CITY, UT 84111-1470
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
—
—
261QR0200X
Radiology Clinic/Center
Primary
—
—
Other
Enumeration date
01/19/2023
Last updated
11/20/2023
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