Healthcare Provider Details

I. General information

NPI: 1891182721
Provider Name (Legal Business Name): ULTIMATE EYECARE SANTA FE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GALISTEO ST
SANTA FE NM
87505-4752
US

IV. Provider business mailing address

PO BOX 6177
SANTA FE NM
87502-6177
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-7746
  • Fax: 505-983-6846
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number371
License Number StateNM

VIII. Authorized Official

Name: MARK A RASMUSSEN
Title or Position: OWNER
Credential: OD
Phone: 505-983-7746