Healthcare Provider Details

I. General information

NPI: 1356468755
Provider Name (Legal Business Name): ALVERNON OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 E 32ND ST
SILVER CITY NM
88061-7229
US

IV. Provider business mailing address

1212 E 32ND ST
SILVER CITY NM
88061-7229
US

V. Phone/Fax

Practice location:
  • Phone: 505-538-2770
  • Fax: 520-538-9611
Mailing address:
  • Phone: 505-538-2770
  • Fax: 520-538-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number813
License Number StateAZ

VIII. Authorized Official

Name: STACIA A DECKER
Title or Position: VP OF RETAIL
Credential: LDO
Phone: 520-327-6215