Provider Demographics
NPI:1669466900
Name:CLOVIS VISION ASSOCIATES PA
Entity Type:Organization
Organization Name:CLOVIS VISION ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:WILLMON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:575-763-5522
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-0700
Mailing Address - Country:US
Mailing Address - Phone:575-763-5522
Mailing Address - Fax:575-763-4722
Practice Address - Street 1:1217 PILE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5944
Practice Address - Country:US
Practice Address - Phone:575-763-5522
Practice Address - Fax:575-763-4722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM291152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00P428OtherBCBS
NM0173070001Medicare NSC
NMU02943Medicare UPIN
NMU02949Medicare UPIN
NMT74915Medicare UPIN
NM0173070001Medicare Oscar/Certification