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General NPI Number Information
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NPI Number | 1356431605
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Entity Type | Organization
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Legal Business Name | SOUTHWEST VISION SPECIALISTS, P.A.
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Dates
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Enumeration Date | 10/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1680 CALLE DE ALVAREZ
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City | LAS CRUCES
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State | NM
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Zip | 88005
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Country | US
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Telephone | 505-526-5367
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Fax | 505-526-5057
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Provider Business Mailing Address
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Address Line | PO BOX 130
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City | MESILLA PARK
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State | NM
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Zip | 88047-0130
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Country | US
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Telephone | 505-526-5367
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Fax | 505-526-5057
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. BRENT EDWARD SHELLEY
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Credential | OD
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Telephone | 505-526-5367
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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 | OP2549
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License Number State | NM
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