1770640500 NPI number — ALBUQUERQUE VISION CLINIC LLC

Table of content: (NPI 1770640500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770640500 NPI number — ALBUQUERQUE VISION CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBUQUERQUE VISION CLINIC 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:
1770640500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5343 WYOMING BLVD NE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-3199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-332-2020
Provider Business Mailing Address Fax Number:
505-856-7820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5343 WYOMING BLVD NE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-3199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-332-2020
Provider Business Practice Location Address Fax Number:
505-856-7820
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GANSEL ANG
Authorized Official First Name:
KARLYN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
505-332-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OP2-299 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1346213154 . This is a "NPI PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1578538872 . This is a "NPI PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1467425769 . This is a "NPI PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1619942398 . This is a "NPI PROVIDER NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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