Healthcare Provider Details

I. General information

NPI: 1700147964
Provider Name (Legal Business Name): T OR C EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 N DATE STREET
TRUTH OR CONSEQUENCES NM
87901-2346
US

IV. Provider business mailing address

518 N DATE STREET
TRUTH OR CONSEQUENCES NM
87901-2346
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-7811
  • Fax:
Mailing address:
  • Phone: 575-894-7811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN B ANDERSON
Title or Position: OWNER
Credential: MD
Phone: 575-805-5574