Healthcare Provider Details

I. General information

NPI: 1669833166
Provider Name (Legal Business Name): CASEY OPTICAL TOO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2231
US

IV. Provider business mailing address

9000 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2231
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-3113
  • Fax: 505-792-6608
Mailing address:
  • Phone: 505-219-3113
  • Fax: 505-792-6608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLY ADAMS BRODERICK
Title or Position: MANAGING MEMBER
Credential:
Phone: 505-379-2158