Provider Demographics
NPI:1417052978
Name:SOUTHWEST OPTICAL, LLC
Entity Type:Organization
Organization Name:SOUTHWEST OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-524-2666
Mailing Address - Street 1:2030 S SOLANO
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:505-532-6002
Mailing Address - Fax:505-521-1007
Practice Address - Street 1:2030 S SOLANO
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:505-532-6002
Practice Address - Fax:505-521-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4817870001Medicare ID - Type Unspecified