Healthcare Provider Details

I. General information

NPI: 1215016415
Provider Name (Legal Business Name): INDIAN WELLS ULTRASOUND IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W BOUTZ RD. BLDG #1
LAS CRUCES NM
88005
US

IV. Provider business mailing address

PO BOX 1744
ALAMOGORDO NM
88311-1744
US

V. Phone/Fax

Practice location:
  • Phone: 505-532-7000
  • Fax: 505-532-7129
Mailing address:
  • Phone: 505-443-0339
  • Fax: 505-434-5624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number106930
License Number StateNM

VIII. Authorized Official

Name: MR. CHARLES JACKSON WOODDELL
Title or Position: PRESIDENT
Credential: RDMS
Phone: 505-443-0339