Tellica Imaging, LLC
NPI 1205554367ActiveOrganization· Physiological Laboratory· Bountiful, UT
Physiological Laboratory in Bountiful, Utah, registered in NPPES in August 2022, part of Intermountain Healthcare. The authorized official on file is Nannette Mignon Berensen, Ceo. Enrolled in Medicare as part b supplier - independent diagnostic testing facility (idtf).
Overview
| NPI | 1205554367 |
|---|---|
| Status | Active |
| Entity type | Organization (subpart) |
| Parent organization | Intermountain Healthcare |
| NPI issued | Aug 16, 2022 |
| Last updated in NPPES | Feb 7, 2023 |
| Certified by provider | Feb 7, 2023 |
Specialties and licenses
| Taxonomy | Code | License | State |
|---|---|---|---|
| Physiological Laboratory Primary | 293D00000X | — | — |
| Clinic/Center, Radiology | 261QR0200X | — | — |
Exclusion screening
| List | Result | Details |
|---|---|---|
| HHS-OIG LEIE · Oct 9, 2026 | No match | Checked by NPI and by name + state |
| North Carolina Medicaid · Nov 10, 2026 | No match | — |
| New York OMIG · Nov 10, 2026 | No match | — |
| Ohio Medicaid · Nov 10, 2026 | No match | — |
| Pennsylvania Medicheck · Nov 10, 2026 | No match | — |
| Washington HCA · Nov 10, 2026 | No match | — |
Official OIG search · How matching works ·Bulk check a roster
Medicare
| Enrollment (PECOS) | Enrolled Part B Supplier - Independent Diagnostic Testing Facility (Idtf) (UT) |
|---|