Healthcare Provider Details

I. General information

NPI: 1437660040
Provider Name (Legal Business Name): PECOS VALLEY EYE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 SE MAIN STREET
ROSWELL NM
88203
US

IV. Provider business mailing address

8801 HORIZON BLVD NE STE 360
ALBUQUERQUE NM
87113-1563
US

V. Phone/Fax

Practice location:
  • Phone: 505-768-1333
  • Fax: 505-244-9566
Mailing address:
  • Phone: 505-768-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DAWN K GERENCER
Title or Position: DIRECTOR OF AMBULATORY SURGICAL SER
Credential: RN, BSN, CNOR, CASC
Phone: 505-768-1333