Basic Information
| Provider Information | |||||||||
| NPI: | 1003846726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN RADIOLOGY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1175 58TH AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806344808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704950300 | ||||||||
| FaxNumber: | 9702249624 | ||||||||
| Practice Location | |||||||||
| Address1: | 5285 MCWHINNEY BLVD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805388863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702784181 | ||||||||
| FaxNumber: | 9702784180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 11/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | GOODMAN | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9706698881 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |
ID Information
| ID | Type | State | Issuer | Description | 75251370 | 05 | CO | MEDICAID |