1710481726 NPI number — DESERT MOUNTAIN EYECARE LLC

Table of content: (NPI 1710481726)

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)