Provider Demographics
NPI:1336297712
Name:WILSON RADIOGRAPHIC CENTER OF ALBUQUERQUE, INC
Entity Type:Organization
Organization Name:WILSON RADIOGRAPHIC CENTER OF ALBUQUERQUE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:DA
Authorized Official - Phone:505-883-5066
Mailing Address - Street 1:3901 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1577
Mailing Address - Country:US
Mailing Address - Phone:505-883-5066
Mailing Address - Fax:505-888-9466
Practice Address - Street 1:3901 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1577
Practice Address - Country:US
Practice Address - Phone:505-883-5066
Practice Address - Fax:505-888-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMFA0000071292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory