Healthcare Provider Details

I. General information

NPI: 1295765360
Provider Name (Legal Business Name): LAS CRUCES PET IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 MALL DRIVE SUITE D
LAS CRUCES NM
88011-8102
US

IV. Provider business mailing address

P.O. BOX 676072
DALLAS TX
75267-6072
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5540
  • Fax: 575-522-3259
Mailing address:
  • Phone: 740-266-4908
  • Fax: 740-264-4376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number3834
License Number StateNM

VIII. Authorized Official

Name: CHUCK WILTSHIRE
Title or Position: CEO
Credential:
Phone: 919-349-6300