Provider Demographics
NPI:1194798397
Name:TETON OPEN MRI OF POCATELLO, LLC
Entity type:Organization
Organization Name:TETON OPEN MRI OF POCATELLO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-552-0828
Mailing Address - Street 1:246 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3356
Mailing Address - Country:US
Mailing Address - Phone:208-552-0828
Mailing Address - Fax:208-552-0829
Practice Address - Street 1:246 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3356
Practice Address - Country:US
Practice Address - Phone:208-552-0828
Practice Address - Fax:208-552-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology