NPIMap

Organization Active NPI

Tellica Imaging, LLC

  • Physiological Laboratory
  • Bountiful, UT
National Provider Identifier
1205554367
Registry record updated Feb 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physiological LaboratoryTaxonomy code 293D00000X
Legal business name
TELLICA IMAGING, LLC
Practice address
110 N Main St
Bountiful, UT 84010-6134
Phone
(801) 442-5737
NPI assigned
Aug 16, 2022
Organization subpart
Yes
Parent organization
INTERMOUNTAIN HEALTHCAREAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 7, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Nannette Mignon Berensen
Title
Ceo
Phone
(801) 507-8002

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Radiology Clinic/Center 261QR0200X
Physiological Laboratory 293D00000X Primary

Addresses

Primary practice location

110 N Main St
Bountiful, UT 84010-6134

Mailing address

36 S State St
Salt Lake City, UT 84111-1401

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230508000797 UT Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 3577950765 1 other NPI on this enrollment
Practice locations: Bountiful, UT

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Tellica Imaging LLC10 organizations share this tax ID, including this one
Part of
Duchesne Valley Clinic

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1028 Chambers St
South Ogden, UT 84403
Phone (801) 387-8670

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1660608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675728000000",
    "number": "1205554367",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36 S STATE ST",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841111401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "110 N MAIN ST",
            "city": "BOUNTIFUL",
            "state": "UT",
            "postal_code": "840106134",
            "telephone_number": "801-442-5737"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TELLICA IMAGING, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "INTERMOUNTAIN HEALTHCARE",
        "enumeration_date": "2022-08-16",
        "last_updated": "2023-02-07",
        "certification_date": "2023-02-07",
        "status": "A",
        "authorized_official_last_name": "BERENSEN",
        "authorized_official_first_name": "NANNETTE",
        "authorized_official_middle_name": "MIGNON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "801-507-8002"
    },
    "taxonomies": [
        {
            "code": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "293D00000X",
            "taxonomy_group": "",
            "desc": "Physiological Laboratory",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bountiful, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.