Healthcare Provider Details

I. General information

NPI: 1861659856
Provider Name (Legal Business Name): KEITH D. BARKER OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 E LLANO ESTACADO BLVD
CLOVIS NM
88101-3758
US

IV. Provider business mailing address

PO BOX 609
CLOVIS NM
88102-0609
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2339
  • Fax:
Mailing address:
  • Phone: 575-769-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2239T
License Number StateNM

VIII. Authorized Official

Name: MR. KEITH D BARKER
Title or Position: OWNER
Credential: OD PC
Phone: 505-769-2339