Provider Demographics
NPI:1215053202
Name:ALASKA INNOVATIVE IMAGING, LLC
Entity type:Organization
Organization Name:ALASKA INNOVATIVE IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD MRI TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-561-9191
Mailing Address - Street 1:2110 E NORTHERN LIGHTS BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4102
Mailing Address - Country:US
Mailing Address - Phone:907-561-9191
Mailing Address - Fax:907-561-0097
Practice Address - Street 1:2110 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4102
Practice Address - Country:US
Practice Address - Phone:907-561-9191
Practice Address - Fax:907-561-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4202932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty