Healthcare Provider Details

I. General information

NPI: 1114193935
Provider Name (Legal Business Name): BOTWIN EYE GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 SAINT MICHAELS DR BUILDING A
SANTA FE NM
87505-7620
US

IV. Provider business mailing address

444 SAINT MICHAELS DR BUILDING A
SANTA FE NM
87505-7620
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-4442
  • Fax:
Mailing address:
  • Phone: 505-954-4442
  • Fax: 505-954-4448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARK BOTWIN
Title or Position: OWNER
Credential:
Phone: 505-954-4442