Healthcare Provider Details

I. General information

NPI: 1841274313
Provider Name (Legal Business Name): L VICTOR SANDOVAL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S TELSHOR BLVD STE 1534
LAS CRUCES NM
88011-4669
US

IV. Provider business mailing address

700 S TELSHOR BLVD STE 1534
LAS CRUCES NM
88011-4669
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-8334
  • Fax: 575-522-1065
Mailing address:
  • Phone: 575-522-8334
  • Fax: 575-522-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number260
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: