Healthcare Provider Details

I. General information

NPI: 1336297712
Provider Name (Legal Business Name): WILSON RADIOGRAPHIC CENTER OF ALBUQUERQUE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LOUISIANA BLVD NE SUITE E
ALBUQUERQUE NM
87110-1577
US

IV. Provider business mailing address

3901 LOUISIANA BLVD NE SUITE E
ALBUQUERQUE NM
87110-1577
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-5066
  • Fax: 505-888-9466
Mailing address:
  • Phone: 505-883-5066
  • Fax: 505-888-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License NumberFA0000071
License Number StateNM

VIII. Authorized Official

Name: MS. DEBRA BURNS
Title or Position: OWNER
Credential: D.A.
Phone: 505-883-5066