Healthcare Provider Details

I. General information

NPI: 1730476748
Provider Name (Legal Business Name): SOUTHERN NEW MEXICO DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 E LOHMAN AVE SUITE C
LAS CRUCES NM
88011-8288
US

IV. Provider business mailing address

PO BOX 13668
LAS CRUCES NM
88013-3668
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-1974
  • Fax: 575-522-5209
Mailing address:
  • Phone: 575-522-1974
  • Fax: 575-522-5209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRETT R. HENDERSON
Title or Position: OFFICER
Credential: M.D.
Phone: 525-522-1974