Healthcare Provider Details

I. General information

NPI: 1770731168
Provider Name (Legal Business Name): SOUTH WEST EYEWEAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

210 W COAL AVE
GALLUP NM
87301-6306
US

IV. Provider business mailing address

210 W COAL AVE
GALLUP NM
87301-6306
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-2121
  • Fax: 505-722-2537
Mailing address:
  • Phone: 505-722-2121
  • Fax: 505-722-2537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0800001830
License Number StateNM

VIII. Authorized Official

Name: MR. RUSSELL FRANCIS
Title or Position: OWNER
Credential:
Phone: 505-722-2121