Provider Demographics
NPI:1871713909
Name:ROSWELL CLINIC CORP
Entity type:Organization
Organization Name:ROSWELL CLINIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:866-419-4057
Mailing Address - Fax:
Practice Address - Street 1:601 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5224
Practice Address - Country:US
Practice Address - Phone:575-625-1393
Practice Address - Fax:575-625-1296
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSWELL CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-30
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5805930001Medicare NSC