Healthcare Provider Details

I. General information

NPI: 1740563444
Provider Name (Legal Business Name): IMAGING CENTER OF CLOVIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 W 21ST ST
CLOVIS NM
88101-4017
US

IV. Provider business mailing address

2105 W 21ST ST
CLOVIS NM
88101-4017
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-9729
  • Fax: 575-935-9731
Mailing address:
  • Phone: 575-935-9729
  • Fax: 575-935-9731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JEANANNE MAZZOLINI
Title or Position: OWNER
Credential: RT( R)( M)
Phone: 575-693-3770