Provider Demographics
NPI:1295765360
Name:LAS CRUCES PET IMAGING, LLC
Entity type:Organization
Organization Name:LAS CRUCES PET IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:WILTSHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-349-6300
Mailing Address - Street 1:P.O. BOX 676072
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6072
Mailing Address - Country:US
Mailing Address - Phone:740-266-4908
Mailing Address - Fax:740-264-4376
Practice Address - Street 1:1121 MALL DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8102
Practice Address - Country:US
Practice Address - Phone:575-522-5540
Practice Address - Fax:575-522-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2471N0900X
NM38342471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49439065Medicaid
NM300521065Medicare PIN