1710481726 NPI number — DESERT MOUNTAIN EYECARE 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 1710481726 NPI number — DESERT MOUNTAIN EYECARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
DESERT MOUNTAIN EYECARE 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:
1710481726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1105 CARMEL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO COMMUNITIES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87002-5941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-610-7625
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5504 MENAUL BLVD NE STE AANDB
Provider Second Line Business Practice Location Address:
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:
505-610-7626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PACHECO
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
SUNNY
Authorized Official Title or Position:
OPTOMETRY
Authorized Official Telephone Number:
505-610-7626

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)