Healthcare Provider Details

I. General information

NPI: 1922011410
Provider Name (Legal Business Name): CLED T CLICK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N 3RD AVE
CLAYTON NM
88415-3300
US

IV. Provider business mailing address

315 N 3RD AVE
CLAYTON NM
88415-3300
US

V. Phone/Fax

Practice location:
  • Phone: 575-374-2533
  • Fax: 575-374-2533
Mailing address:
  • Phone: 575-374-2533
  • Fax: 575-374-2533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number198
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1942
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: