Provider Demographics
NPI:1215016415
Name:INDIAN WELLS ULTRASOUND IMAGING INC
Entity Type:Organization
Organization Name:INDIAN WELLS ULTRASOUND IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:WOODDELL
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:505-443-0339
Mailing Address - Street 1:PO BOX 1744
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-1744
Mailing Address - Country:US
Mailing Address - Phone:505-443-0339
Mailing Address - Fax:505-434-5624
Practice Address - Street 1:205 W BOUTZ RD. BLDG #1
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:505-532-7000
Practice Address - Fax:505-532-7129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106930261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology