Healthcare Provider Details

I. General information

NPI: 1639588114
Provider Name (Legal Business Name): LINDA LY BIANCIOTTO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 301 NORTH B STREET
ZUNI NM
87327
US

IV. Provider business mailing address

PO BOX 1785
ZUNI NM
87327
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-7485
  • Fax:
Mailing address:
  • Phone: 505-782-7485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2035
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: