Provider Demographics
NPI:1487657862
Name:FILLMORE EYE CLINIC INCORPORATED
Entity Type:Organization
Organization Name:FILLMORE EYE CLINIC INCORPORATED
Other - Org Name:FILLMORE EYE CLINIC ASC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PARLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-434-1200
Mailing Address - Street 1:1124 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6414
Mailing Address - Country:US
Mailing Address - Phone:575-434-1200
Mailing Address - Fax:575-437-3947
Practice Address - Street 1:1124 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:575-434-1200
Practice Address - Fax:575-437-3947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6134261QA1903X
NM3343261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850273244-001OtherTRICARE
NM15215OtherPRESBYTERIAN
NMSS06OtherBLUE CROSS/BLUE SHEILD
NM40071Medicaid
NM850273244-001OtherTRICARE
NM40071Medicaid