Healthcare Provider Details

I. General information

NPI: 1821127499
Provider Name (Legal Business Name): SOUTHWEST EYE CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date: 07/18/2008
Reactivation Date: 11/26/2008

III. Provider practice location address

2030 S SOLANO DR
LAS CRUCES NM
88001-5402
US

IV. Provider business mailing address

2030 S SOLANO DR
LAS CRUCES NM
88001-5402
US

V. Phone/Fax

Practice location:
  • Phone: 505-521-1158
  • Fax: 505-521-1007
Mailing address:
  • Phone: 505-521-1158
  • Fax: 505-521-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number83137
License Number StateNM

VIII. Authorized Official

Name: ROBERT L. VILLALOBOS JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 575-521-1158