Healthcare Provider Details

I. General information

NPI: 1316100225
Provider Name (Legal Business Name): RUIDOSO NATIONAL OPTICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 HIGHWAY 70 WEST
RUIDOSO DOWNS NM
88346
US

IV. Provider business mailing address

301 SAN MATEO BLVD SE
ALBUQUERQUE NM
87108-2919
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-9410
  • Fax: 505-255-9875
Mailing address:
  • Phone: 505-378-7148
  • Fax: 505-378-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number251
License Number StateNM

VIII. Authorized Official

Name: DR. BILL G MCDONALD
Title or Position: PROVIDER
Credential: O.D.
Phone: 505-378-7148