Healthcare Provider Details

I. General information

NPI: 1396042792
Provider Name (Legal Business Name): EYES OF NM FAMILY OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 EL PUEBLO RD NW
LOS RANCHOS NM
87114-1105
US

IV. Provider business mailing address

7007 WYOMING BLVD NE SUITE C-1
ALBUQUERQUE NM
87109-3987
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-0826
  • Fax:
Mailing address:
  • Phone: 505-828-3937
  • Fax: 505-715-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number611
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number611
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number611
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number611
License Number StateNM

VIII. Authorized Official

Name: DR. TIFFANY GARCIA MARTINEZ
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 505-385-0826