Provider Demographics
NPI:1558304923
Name:INTERMOUNTAIN DIAGNOSTICS INC.
Entity type:Organization
Organization Name:INTERMOUNTAIN DIAGNOSTICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/SEC/TREAS
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ASPELUND
Authorized Official - Suffix:
Authorized Official - Credentials:RVT
Authorized Official - Phone:208-331-0436
Mailing Address - Street 1:200 NORTH 4TH STREET
Mailing Address - Street 2:SUITE 15
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-331-0436
Mailing Address - Fax:208-331-3443
Practice Address - Street 1:200 N 4TH ST
Practice Address - Street 2:SUITE 15
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6001
Practice Address - Country:US
Practice Address - Phone:208-331-0436
Practice Address - Fax:208-331-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1400523Medicare ID - Type Unspecified