Healthcare Provider Details

I. General information

NPI: 1750713566
Provider Name (Legal Business Name): JUSTIN F CHIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

PO BOX 1337 DEPT 18 (EYE CLINIC)
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1397
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0002990
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: