Healthcare Provider Details

I. General information

NPI: 1306519541
Provider Name (Legal Business Name): SAMUEL SMITH COA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2021
Last Update Date: 07/25/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

13 BACUS AVE APT 9
DURANGO CO
81301-4161
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 971-258-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License NumberCOA
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: