Healthcare Provider Details

I. General information

NPI: 1174975114
Provider Name (Legal Business Name): BEHAVIORAL OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 TESUQUE VILLAGE RD UNIT 458
TESUQUE NM
87574-2000
US

IV. Provider business mailing address

174 TESUQUE VILLAGE RD UNIT 458
TESUQUE NM
87574-2000
US

V. Phone/Fax

Practice location:
  • Phone: 505-469-4949
  • Fax:
Mailing address:
  • Phone: 505-469-4949
  • Fax:

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: DR. SAMUEL A BERNE
Title or Position: OWNER
Credential: OD
Phone: 505-469-4949