Provider Demographics
NPI:1538466099
Name:GRANT COUNTY IMAGING CENTER LLC
Entity Type:Organization
Organization Name:GRANT COUNTY IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAMAKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVASTHALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-556-1800
Mailing Address - Street 1:205 W BOUTZ RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3259
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:575-532-7025
Practice Address - Street 1:1600 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7287
Practice Address - Country:US
Practice Address - Phone:575-534-9033
Practice Address - Fax:575-534-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology