Provider Demographics
NPI:1215019237
Name:CEDAR CREST VISION LLC
Entity Type:Organization
Organization Name:CEDAR CREST VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER OF LLC
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:QUICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-286-0300
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-1640
Mailing Address - Country:US
Mailing Address - Phone:505-286-0300
Mailing Address - Fax:505-281-4765
Practice Address - Street 1:12220 NORTH HIGHWAY 14
Practice Address - Street 2:SUITE 3
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008
Practice Address - Country:US
Practice Address - Phone:505-286-0300
Practice Address - Fax:505-281-4765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65109333Medicaid
NM700521096Medicare PIN
NM65109333Medicaid