1023172293 NPI number — FAMILY VISION CENTER, LLC

Table of content: (NPI 1023172293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023172293 NPI number — FAMILY VISION CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY VISION CENTER, 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:
1023172293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 W AVENUE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88260-4212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-396-2522
Provider Business Mailing Address Fax Number:
575-396-7655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 W AVENUE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88260-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-396-2522
Provider Business Practice Location Address Fax Number:
575-396-7655
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REBER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
BRYCE
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
575-396-2522

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)

  • Identifier: NM00P493 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: P1875 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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