Healthcare Provider Details

I. General information

NPI: 1740620327
Provider Name (Legal Business Name): CONTACT LENS GALLERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 RIVERSIDE PLAZA LN NW STE B
ALBUQUERQUE NM
87120-2641
US

IV. Provider business mailing address

6321 RIVERSIDE PLAZA LN NW STE B
ALBUQUERQUE NM
87120-2641
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-3937
  • Fax: 505-899-1224
Mailing address:
  • Phone: 505-897-3937
  • Fax: 505-899-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberFA0005635
License Number StateNM

VIII. Authorized Official

Name: DR. JUDY ANN PEREA-MAES
Title or Position: PROPRIETOR
Credential: OD
Phone: 505-897-3937