Healthcare Provider Details

I. General information

NPI: 1295054351
Provider Name (Legal Business Name): EYE CARE OF NEW MEXICO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 EUBANK BLVD SE STE. A
ALBUQUERQUE NM
87123-3338
US

IV. Provider business mailing address

500 EUBANK BLVD SE STE. A
ALBUQUERQUE NM
87123-3338
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-2555
  • Fax: 505-323-0888
Mailing address:
  • Phone: 505-323-2555
  • Fax: 505-323-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number547
License Number StateNM

VIII. Authorized Official

Name: DR. WENDE T. WAGGONER
Title or Position: PRESIDENT/OPTOMETRIST
Credential: O.D., M.P.H., M.S.
Phone: 505-323-2555