MEDICARE: ANASAZI EYECARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1902081458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANASAZI EYECARE LLC

Provider Business Mailing Address
First Line	:	800 TRINITY DR STE J
Second Line	:
City	:	LOS ALAMOS
State	:	NM
Zip	:	87544-4105
Country	:	US
Telephone Number	:	505-662-7000
Fax Number	:	505-662-2949

Provider Business Practice Location Address
First Line	:	800 TRINITY DR STE J
Second Line	:
City	:	LOS ALAMOS
State	:	NM
Zip	:	87544-4105
Country	:	US
Telephone Number	:	505-662-7000
Fax Number	:	505-662-2949

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WENDE WAGGONER
Credential	:
Telephone Number	:	505-662-7000

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	01/03/2008

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Directions to “ANASAZI EYECARE LLC ” Practice Location

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