Provider Demographics
NPI:1043423379
Name:ROSWELL CLINIC CORP
Entity Type:Organization
Organization Name:ROSWELL CLINIC CORP
Other - Org Name:MESA MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:330 FRANKLIN RD
Mailing Address - Street 2:#135A-599
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:505-622-1841
Practice Address - Fax:505-622-5316
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSWELL CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-07
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5805930002Medicare NSC