Healthcare Provider Details

I. General information

NPI: 1346362845
Provider Name (Legal Business Name): EYE DEAL VISION P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511A HIGHWAY 314 SW
LOS LUNAS NM
87031-9600
US

IV. Provider business mailing address

511A HIGHWAY 314 SW
LOS LUNAS NM
87031-9600
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-3937
  • Fax: 505-565-3900
Mailing address:
  • Phone: 505-565-3937
  • Fax: 505-565-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1551
License Number StateNM

VIII. Authorized Official

Name: MRS. MELLISA R FLOWERS
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-565-3937