Provider Demographics
NPI:1437660040
Name:PECOS VALLEY EYE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:PECOS VALLEY EYE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AMBULATORY SURGICAL SER
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GERENCER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, CNOR, CASC
Authorized Official - Phone:505-768-1333
Mailing Address - Street 1:8801 HORIZON BLVD NE STE 360
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1563
Mailing Address - Country:US
Mailing Address - Phone:505-768-1333
Mailing Address - Fax:
Practice Address - Street 1:1610 SE MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203
Practice Address - Country:US
Practice Address - Phone:505-768-1333
Practice Address - Fax:505-244-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery