Provider Demographics
NPI:1922057827
Name:PINON HILLS OPTICAL INC
Entity Type:Organization
Organization Name:PINON HILLS OPTICAL INC
Other - Org Name:NEW MEXICO EYE CLINIC OPTICAL SHOP
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-325-5021
Mailing Address - Street 1:2300 E 30TH ST
Mailing Address - Street 2:STE 105
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-325-4298
Mailing Address - Fax:505-326-4690
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:STE 105
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-325-4298
Practice Address - Fax:505-326-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3934680001Medicare NSC