Provider Demographics
NPI:1740563444
Name:IMAGING CENTER OF CLOVIS, LLC
Entity Type:Organization
Organization Name:IMAGING CENTER OF CLOVIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZOLINI
Authorized Official - Suffix:
Authorized Official - Credentials:RT( R)( M)
Authorized Official - Phone:575-693-3770
Mailing Address - Street 1:2105 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4017
Mailing Address - Country:US
Mailing Address - Phone:575-935-9729
Mailing Address - Fax:575-935-9731
Practice Address - Street 1:2105 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4017
Practice Address - Country:US
Practice Address - Phone:575-935-9729
Practice Address - Fax:575-935-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography