1497319693 NPI number — CLEAR CHOICE VISION CARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497319693 NPI number — CLEAR CHOICE VISION CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR CHOICE VISION CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497319693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6020 SILVER LEAF TRL NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87111-8095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-282-2146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6600 MENAUL BLVE NE
Provider Second Line Business Practice Location Address:
SUITE M5A
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-282-2146
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
JENTZEN
Authorized Official First Name:
RANDAL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OPTOMETRIST/OWNER
Authorized Official Telephone Number:
806-282-2146

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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