Provider Demographics
NPI:1730476748
Name:SOUTHERN NEW MEXICO DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:SOUTHERN NEW MEXICO DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:525-522-1974
Mailing Address - Street 1:PO BOX 13668
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3668
Mailing Address - Country:US
Mailing Address - Phone:575-522-1974
Mailing Address - Fax:575-522-5209
Practice Address - Street 1:3850 E LOHMAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8288
Practice Address - Country:US
Practice Address - Phone:575-522-1974
Practice Address - Fax:575-522-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMB2507Medicare PIN