Basic Information
| Provider Information | |||||||||
| NPI: | 1700852373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALAMOGORDO IMAGING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8020 CONSTITUTION PLACE NE | ||||||||
| Address2: | #202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Practice Location | |||||||||
| Address1: | 2539 MEDICAL DR | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054341353 | ||||||||
| FaxNumber: | 5054341398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRANDT | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5059983096 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 43551882 | 05 | NM | MEDICAID | NMA100416 | 01 | NM | MEDICARE | OTHER |