MEDICARE: LAS CRUCES PET IMAGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471N0900X	Nuclear Medicine Technology Radiologic Technologist
2	2471N0900X	Nuclear Medicine Technology Radiologic Technologist	3834	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295765360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS CRUCES PET IMAGING, LLC

Provider Business Mailing Address
First Line	:	P.O. BOX 676072
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-6072
Country	:	US
Telephone Number	:	740-266-4908
Fax Number	:	740-264-4376

Provider Business Practice Location Address
First Line	:	1121 MALL DRIVE
Second Line	:	SUITE D
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8102
Country	:	US
Telephone Number	:	575-522-5540
Fax Number	:	575-522-3259

Authorized Official
Title or Position	:	CEO
Name	:	CHUCK WILTSHIRE
Credential	:
Telephone Number	:	919-349-6300

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	01/19/2012

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