Healthcare Provider Details

I. General information

NPI: 1255720983
Provider Name (Legal Business Name): DRS MCCLOSKEY AND MENEAKIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N PASEO DE ONATE
ESPANOLA NM
87532-2963
US

IV. Provider business mailing address

612 N PASEO DE ONATE
ESPANOLA NM
87532-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7355
  • Fax: 505-753-7533
Mailing address:
  • Phone: 505-753-7355
  • Fax: 505-753-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number231
License Number StateNM

VIII. Authorized Official

Name: MICHAEL MENEAKIS
Title or Position: OPTOMETRIST
Credential: OD
Phone: 505-753-7355