Healthcare Provider Details

I. General information

NPI: 1144592304
Provider Name (Legal Business Name): RANDALL DEAN WILCOX LAB DIRECTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 FOSSIL VIEW RD
LAS CRUCES NM
88007
US

IV. Provider business mailing address

PO BOX 155
RADIUM SPRINGS NM
88054-0155
US

V. Phone/Fax

Practice location:
  • Phone: 575-520-3254
  • Fax:
Mailing address:
  • Phone: 575-520-3254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: