Provider Demographics
NPI:1144592304
Name:WILCOX, RANDALL DEAN (LAB DIRECTOR)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:DEAN
Last Name:WILCOX
Suffix:
Gender:M
Credentials:LAB DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:RADIUM SPRINGS
Mailing Address - State:NM
Mailing Address - Zip Code:88054-0155
Mailing Address - Country:US
Mailing Address - Phone:575-520-3254
Mailing Address - Fax:
Practice Address - Street 1:383 FOSSIL VIEW RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007
Practice Address - Country:US
Practice Address - Phone:575-520-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 251E00000X, 291U00000X, 311ZA0620X, 347C00000X
NM246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No171W00000XOther Service ProvidersContractor
No251E00000XAgenciesHome Health
No291U00000XLaboratoriesClinical Medical Laboratory
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM291U00000XMedicaid
NM347C00000XMedicaid
NM311ZA0620XMedicaid
NM251E00000XMedicaid
NM1144592304Medicaid
NM246RP19000X-PHEBOTOMMedicaid