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General NPI Number Information
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NPI Number | 1710057740
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Entity Type | Organization
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Legal Business Name | MAGNOLIA DIAGNOSTIC CENTER,INC
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2100 N DR MARTIN LUTHER KING JR BLVD
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City | CLOVIS
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State | NM
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Zip | 88101-9412
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Country | US
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Telephone | 509-389-9765
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Fax | 505-213-0132
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Provider Business Mailing Address
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Address Line | 2100 N DR MARTIN LUTHER KING JR BLVD
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City | CLOVIS
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State | NM
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Zip | 88101-9412
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Country | US
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Telephone | 509-389-9765
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Fax | 505-213-0132
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Authorized Official
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Title or Position | PRESIDENT
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Name | RAMON GUTIERREZ
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Credential |
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Telephone | 509-389-9765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State | NM
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