Healthcare Provider Details

I. General information

NPI: 1740744614
Provider Name (Legal Business Name): PREMIER MOBILE LAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 FOSSIL VIEW RD
LAS CRUCES NM
88007-7176
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 Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: RANDALL DEAN WILCOX
Title or Position: CEO
Credential: PHLEBOTOMY
Phone: 575-520-3254