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General NPI Number Information
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NPI Number | 1598029308
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Entity Type | Organization
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Legal Business Name | VISIONWEST, INC.
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Dates
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Enumeration Date | 06/26/2012
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Last Update Date | 10/25/2012
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Provider Practice Location Address
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Address Line | 1610 N RIVERSIDE DR
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City | ESPANOLA
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State | NM
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Zip | 87532-8063
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Country | US
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Telephone | 505-747-0433
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Fax |
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Provider Business Mailing Address
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Address Line | 499 CAMINO PINONES
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City | SANTA FE
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State | NM
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Zip | 87505-7523
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Country | US
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Telephone | 505-984-8989
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Fax | 505-992-1069
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Authorized Official
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Title or Position | OPTOMETRIST / OWNER
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Name | DR. DWIGHT THIBODEAUX
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Credential | DO
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Telephone | 505-984-8989
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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 | NM300
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License Number State | NM
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