Healthcare Provider Details

I. General information

NPI: 1710057740
Provider Name (Legal Business Name): MAGNOLIA DIAGNOSTIC CENTER,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N DR MARTIN LUTHER KING JR BLVD
CLOVIS NM
88101-9412
US

IV. Provider business mailing address

2100 N DR MARTIN LUTHER KING JR BLVD
CLOVIS NM
88101-9412
US

V. Phone/Fax

Practice location:
  • Phone: 509-389-9765
  • Fax: 505-213-0132
Mailing address:
  • Phone: 509-389-9765
  • Fax: 505-213-0132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNM

VIII. Authorized Official

Name: RAMON GUTIERREZ
Title or Position: PRESIDENT
Credential:
Phone: 509-389-9765