Healthcare Provider Details

I. General information

NPI: 1184785784
Provider Name (Legal Business Name): JENNIFER LYNNE PLANITZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 CRESTVIEW DR SE
RIO RANCHO NM
87124-5942
US

IV. Provider business mailing address

4100 CRESTVIEW DR SE
RIO RANCHO NM
87124-5942
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-2020
  • Fax: 505-891-2010
Mailing address:
  • Phone: 505-891-2020
  • Fax: 505-891-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberNMOP2377
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: