=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780853549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYES OF THE SOUTHWEST, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2008
-----------------------------------------------------
Last Update Date | 02/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 N TELSHOR BLVD
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-8230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-523-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2810 N TELSHOR BLVD
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-8230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-523-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDWARD VICTOR HERNANDEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 575-523-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 98290
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------