Basic Information
| Provider Information | |||||||||
| NPI: | 1548879943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE IMAGING, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12554 W. BRIDGER ST. SUITE 118 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837131582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089477000 | ||||||||
| FaxNumber: | 2089476942 | ||||||||
| Practice Location | |||||||||
| Address1: | 12554 W. BRIDGER ST. SUITE 118 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837131582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089477000 | ||||||||
| FaxNumber: | 2089476942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | EWAN | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2089477000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
No ID Information.