Individual
RANDALL DEAN WILCOX
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LAB DIRECTOR
Contact information
Practice address
383 FOSSIL VIEW RD, LAS CRUCES, NM 88007
(575) 520-3254
Mailing address
PO BOX 155, RADIUM SPRINGS, NM 88054-0155
(575) 520-3254
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
—
—
246RP1900X
Phlebotomy Technician
Primary
—
NM
251E00000X
Home Health Agency
—
—
291U00000X
Clinical Medical Laboratory
—
—
311ZA0620X
Adult Care Home Facility
—
—
347C00000X
Private Vehicle
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1144592304
—
NM
05
—
246RP19000X-PHEBOTOM
—
NM
05
—
251E00000X
—
NM
05
—
291U00000X
—
NM
05
—
311ZA0620X
—
NM
05
—
347C00000X
—
NM
Enumeration date
02/03/2012
Last updated
03/15/2019
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