Healthcare Provider Details

I. General information

NPI: 1669466900
Provider Name (Legal Business Name): CLOVIS VISION ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 PILE ST
CLOVIS NM
88101-5944
US

IV. Provider business mailing address

PO BOX 700
CLOVIS NM
88102-0700
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-5522
  • Fax: 575-763-4722
Mailing address:
  • Phone: 575-763-5522
  • Fax: 575-763-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number291
License Number StateNM

VIII. Authorized Official

Name: DR. THOMAS GREGORY WILLMON
Title or Position: PARTNER
Credential: O.D.
Phone: 575-763-5522