=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669833166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASEY OPTICAL TOO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2016
-----------------------------------------------------
Last Update Date | 08/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9000 MENAUL BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-219-3113
-----------------------------------------------------
Fax | 505-792-6608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9000 MENAUL BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-219-3113
-----------------------------------------------------
Fax | 505-792-6608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MS. KIMBERLY ADAMS BRODERICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-379-2158
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------