Provider Demographics
NPI:1013187798
Name:ENGSTROM EYE CENTER LLC
Entity Type:Organization
Organization Name:ENGSTROM EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-625-0123
Mailing Address - Street 1:342 SHERRILL LN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5819
Mailing Address - Country:US
Mailing Address - Phone:575-625-0123
Mailing Address - Fax:575-625-0131
Practice Address - Street 1:342 SHERRILL LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5819
Practice Address - Country:US
Practice Address - Phone:575-625-0123
Practice Address - Fax:575-625-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8525207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB2028Medicare PIN