Healthcare Provider Details

I. General information

NPI: 1104133420
Provider Name (Legal Business Name): SEAN CARLILE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1646 ALAMEDA BLVD NW
ALBUQUERQUE NM
87114-8807
US

IV. Provider business mailing address

12400 MONTGOMERY BLVD NE APT 32
ALBUQUERQUE NM
87111-4164
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-3937
  • Fax: 505-792-3501
Mailing address:
  • Phone: 505-999-7234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number623
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: