Healthcare Provider Details

I. General information

NPI: 1215927215
Provider Name (Legal Business Name): EAST MOUNTAIN EYE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1917 OLD ROUTE 66, EDGEWOOD PLAZA SUITE D-1
EDGEWOOD NM
87015
US

IV. Provider business mailing address

PO BOX 400
EDGEWOOD NM
87015-0400
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-2020
  • Fax: 505-286-2244
Mailing address:
  • Phone: 505-286-2020
  • Fax: 505-286-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberNM425
License Number StateNM

VIII. Authorized Official

Name: DR. PATRIA DULCE WALKER
Title or Position: PRESIDENT
Credential: O.D.
Phone: 505-286-2020