Healthcare Provider Details

I. General information

NPI: 1174743280
Provider Name (Legal Business Name): FASHION OPTICAL AND SUNWEAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 MENAUL BLVD NE
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

7415 MENAUL BLVD NE
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-3991
  • Fax: 505-830-2974
Mailing address:
  • Phone: 505-888-3991
  • Fax: 505-830-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number03074110006
License Number StateNM

VIII. Authorized Official

Name: MS. ANNETTE M BACA
Title or Position: MANAGER
Credential:
Phone: 505-888-3991