Healthcare Provider Details

I. General information

NPI: 1215665377
Provider Name (Legal Business Name): GOLDEN SKILLET, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 CHRISTOPHER DR
BELEN NM
87002-2617
US

IV. Provider business mailing address

1606 JACK NICKLAUS DR
RIO COMMUNITIES NM
87002-5925
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-7781
  • Fax:
Mailing address:
  • Phone: 505-859-5934
  • Fax: 505-212-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN WILLIAM DIETERICHS
Title or Position: OWNER
Credential:
Phone: 505-859-5934