Healthcare Provider Details

I. General information

NPI: 1356660252
Provider Name (Legal Business Name): FILLMORE EYE CLINIC INC, ASC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 10TH ST
ALAMOGORDO NM
88310-6414
US

IV. Provider business mailing address

1124 10TH ST
ALAMOGORDO NM
88310-6414
US

V. Phone/Fax

Practice location:
  • Phone: 575-434-1200
  • Fax: 575-437-3947
Mailing address:
  • Phone: 575-434-1200
  • Fax: 575-437-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number6134
License Number StateNM

VIII. Authorized Official

Name: PARLEY D FILLMORE
Title or Position: PRESIDENT
Credential: MD, PHD
Phone: 575-434-1200