Healthcare Provider Details

I. General information

NPI: 1073090650
Provider Name (Legal Business Name): GALLUP EYE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 01/10/2021
Certification Date: 01/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 BOARDMAN DR
GALLUP NM
87301-4711
US

IV. Provider business mailing address

816 BOARDMAN DR
GALLUP NM
87301-4711
US

V. Phone/Fax

Practice location:
  • Phone: 505-339-2015
  • Fax: 505-492-0904
Mailing address:
  • Phone: 505-339-2015
  • Fax: 505-492-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANDI MCGRAW
Title or Position: PRESIDENT/OD
Credential: OD
Phone: 505-339-2015