Provider Demographics
NPI:1770640500
Name:ALBUQUERQUE VISION CLINIC LLC
Entity Type:Organization
Organization Name:ALBUQUERQUE VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GANSEL ANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-332-2020
Mailing Address - Street 1:5343 WYOMING BLVD NE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3199
Mailing Address - Country:US
Mailing Address - Phone:505-332-2020
Mailing Address - Fax:505-856-7820
Practice Address - Street 1:5343 WYOMING BLVD NE
Practice Address - Street 2:SUITE 2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3199
Practice Address - Country:US
Practice Address - Phone:505-332-2020
Practice Address - Fax:505-856-7820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2-299152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1346213154OtherNPI PROVIDER NUMBER
NM1578538872OtherNPI PROVIDER NUMBER
NM1467425769OtherNPI PROVIDER NUMBER
NM1619942398OtherNPI PROVIDER NUMBER