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General NPI Number Information
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NPI Number | 1487051066
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Entity Type | Organization
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Legal Business Name | BLUE WHALE, INC
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Dates
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Enumeration Date | 11/26/2014
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Last Update Date | 12/07/2017
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Provider Practice Location Address
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Address Line | 9935 COORS BYP NW STE B
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-6195
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Country | US
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Telephone | 505-899-8993
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Fax | 505-898-8994
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Provider Business Mailing Address
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Address Line | 9935 COORS BYP NW STE B
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-6195
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Country | US
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Telephone | 505-899-8993
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Fax | 505-898-8994
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILLIS S MUNCEY
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Credential | OD
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Telephone | 505-899-8993
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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 | 640
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2427
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License Number State | NM
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