Provider Demographics
NPI:1679011191
Name:OPTOMETRICS PC
Entity Type:Organization
Organization Name:OPTOMETRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:MENEAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-753-7355
Mailing Address - Street 1:612 N PASEO DE ONATE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2963
Mailing Address - Country:US
Mailing Address - Phone:505-753-7355
Mailing Address - Fax:505-753-7533
Practice Address - Street 1:612 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2963
Practice Address - Country:US
Practice Address - Phone:505-753-7355
Practice Address - Fax:505-753-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM307152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM50784552Medicaid
NM50784552Medicaid
NMM50784552Medicaid