Provider Demographics
NPI:1881644433
Name:GILA EYECARE, INC.
Entity Type:Organization
Organization Name:GILA EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MITTICA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:575-388-4464
Mailing Address - Street 1:604 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4847
Mailing Address - Country:US
Mailing Address - Phone:575-388-4464
Mailing Address - Fax:575-388-2014
Practice Address - Street 1:604 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4847
Practice Address - Country:US
Practice Address - Phone:575-388-4464
Practice Address - Fax:575-388-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27502562Medicaid
NM27502562Medicaid