Healthcare Provider Details

I. General information

NPI: 1720162191
Provider Name (Legal Business Name): SAMEUL A BERNE OD, FCOVD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 E PALACE AVE SUITE G
SANTA FE NM
87501-2043
US

IV. Provider business mailing address

227 E PALACE AVE SUITE G
SANTA FE NM
87501-2043
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-2030
  • Fax: 505-984-1082
Mailing address:
  • Phone: 505-984-2030
  • Fax: 505-984-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number398
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: