Provider Demographics
NPI:1912061086
Name:ACCENT ON VISION, SANTA FE LLC
Entity Type:Organization
Organization Name:ACCENT ON VISION, SANTA FE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-984-8989
Mailing Address - Street 1:1409 LUISA ST STE D
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7003
Mailing Address - Country:US
Mailing Address - Phone:505-984-8989
Mailing Address - Fax:505-984-8892
Practice Address - Street 1:1409 LUISA ST STE D
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7003
Practice Address - Country:US
Practice Address - Phone:505-984-8989
Practice Address - Fax:505-984-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM MEDICAIDMedicaid
NMBLUE CROSS BLUE SHIEOtherNM00P121
NMBLUE CROSS BLUE SHIEOtherNM00P121