Provider Demographics
NPI:1437254992
Name:MED PARK OPTICAL SHOPPE
Entity Type:Organization
Organization Name:MED PARK OPTICAL SHOPPE
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:ABOC
Authorized Official - Phone:575-524-2666
Mailing Address - Street 1:1300 EL PASEO
Mailing Address - Street 2:STE F
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-6039
Mailing Address - Country:US
Mailing Address - Phone:575-524-2666
Mailing Address - Fax:575-524-4328
Practice Address - Street 1:1300 EL PASEO
Practice Address - Street 2:STE F
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-6039
Practice Address - Country:US
Practice Address - Phone:575-524-2666
Practice Address - Fax:575-524-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
111906OtherEYE MED VISION CARE
NM0183680001Medicare NSC
111906OtherEYE MED VISION CARE