Provider Demographics
NPI:1801030093
Name:MCGUIRE WOUND & OSTOMY CENTER PC
Entity Type:Organization
Organization Name:MCGUIRE WOUND & OSTOMY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-624-2095
Mailing Address - Street 1:PO BOX 1555
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202
Mailing Address - Country:US
Mailing Address - Phone:575-624-2095
Mailing Address - Fax:575-627-5721
Practice Address - Street 1:1717 W 2ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-2000
Practice Address - Country:US
Practice Address - Phone:575-624-2095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR38567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty