1295765360 NPI number — LAS CRUCES PET IMAGING, LLC

Table of content: (NPI 1295765360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295765360 NPI number — LAS CRUCES PET IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAS CRUCES PET IMAGING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295765360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 676072
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-6072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-266-4908
Provider Business Mailing Address Fax Number:
740-264-4376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 MALL DRIVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-8102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-522-5540
Provider Business Practice Location Address Fax Number:
575-522-3259
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILTSHIRE
Authorized Official First Name:
CHUCK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
919-349-6300

Provider Taxonomy Codes

  • Taxonomy code: 2471N0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471N0900X , with the licence number: 3834 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49439065 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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