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General NPI Number Information
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NPI Number | 1518147602
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Entity Type | Organization
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Legal Business Name | DR DANIEL J DIETERICHS, OPTOMETRISTS, P.C.
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Dates
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Enumeration Date | 11/06/2007
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Last Update Date | 11/06/2007
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Provider Practice Location Address
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Address Line | 837 W CASTILLO AVE
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City | BELEN
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State | NM
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Zip | 87002-3123
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Country | US
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Telephone | 505-864-8992
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Fax | 505-864-8737
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Provider Business Mailing Address
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Address Line | 837 W CASTILLO AVE
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City | BELEN
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State | NM
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Zip | 87002-3123
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Country | US
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Telephone | 505-864-8992
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Fax | 505-864-8737
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MR. BARBARA ANN DIETERICHS
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Credential |
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Telephone | 505-864-8992
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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 | NM0P2390
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License Number State | NM
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