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General NPI Number Information
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NPI Number | 1295054351
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Entity Type | Organization
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Legal Business Name | EYE CARE OF NEW MEXICO, INC.
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Dates
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Enumeration Date | 05/27/2010
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 500 EUBANK BLVD SE STE. A
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-3338
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Country | US
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Telephone | 505-323-2555
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Fax | 505-323-0888
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Provider Business Mailing Address
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Address Line | 500 EUBANK BLVD SE STE. A
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-3338
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Country | US
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Telephone | 505-323-2555
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Fax | 505-323-0888
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Authorized Official
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Title or Position | PRESIDENT/OPTOMETRIST
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Name | DR. WENDE T. WAGGONER
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Credential | O.D., M.P.H., M.S.
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Telephone | 505-323-2555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 547
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License Number State | NM
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