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General NPI Number Information
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NPI Number | 1215016415
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Entity Type | Organization
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Legal Business Name | INDIAN WELLS ULTRASOUND IMAGING INC
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 07/25/2007
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Provider Practice Location Address
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Address Line | 205 W BOUTZ RD. BLDG #1
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City | LAS CRUCES
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State | NM
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Zip | 88005
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Country | US
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Telephone | 505-532-7000
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Fax | 505-532-7129
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Provider Business Mailing Address
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Address Line | PO BOX 1744
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City | ALAMOGORDO
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State | NM
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Zip | 88311-1744
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Country | US
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Telephone | 505-443-0339
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Fax | 505-434-5624
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CHARLES JACKSON WOODDELL
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Credential | RDMS
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Telephone | 505-443-0339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number | 106930
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License Number State | NM
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