Healthcare Provider Details

I. General information

NPI: 1922057827
Provider Name (Legal Business Name): PINON HILLS OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST STE 105
FARMINGTON NM
87401-8990
US

IV. Provider business mailing address

2300 E 30TH ST STE 105
FARMINGTON NM
87401-8990
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-4298
  • Fax: 505-326-4690
Mailing address:
  • Phone: 505-325-4298
  • Fax: 505-326-4690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: PAULA VAUGHAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-325-5021