Healthcare Provider Details

I. General information

NPI: 1538466099
Provider Name (Legal Business Name): GRANT COUNTY IMAGING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E 32ND ST
SILVER CITY NM
88061-7287
US

IV. Provider business mailing address

205 W BOUTZ RD BLDG 1
LAS CRUCES NM
88005-3259
US

V. Phone/Fax

Practice location:
  • Phone: 575-534-9033
  • Fax: 575-534-9057
Mailing address:
  • Phone: 575-532-7000
  • Fax: 575-532-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RAMAKRISHNA DEVASTHALI
Title or Position: MEMBER
Credential: MD
Phone: 575-556-1800