Provider Demographics
NPI:1114193935
Name:BOTWIN EYE GROUP PA
Entity Type:Organization
Organization Name:BOTWIN EYE GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-954-4442
Mailing Address - Street 1:444 SAINT MICHAELS DR
Mailing Address - Street 2:BUILDING A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7620
Mailing Address - Country:US
Mailing Address - Phone:505-954-4442
Mailing Address - Fax:505-954-4448
Practice Address - Street 1:444 SAINT MICHAELS DR
Practice Address - Street 2:BUILDING A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7620
Practice Address - Country:US
Practice Address - Phone:505-954-4442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty