Provider Demographics
NPI:1215927215
Name:EAST MOUNTAIN EYE CLINIC PC
Entity type:Organization
Organization Name:EAST MOUNTAIN EYE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRIA
Authorized Official - Middle Name:DULCE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-286-2020
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-0400
Mailing Address - Country:US
Mailing Address - Phone:505-286-2020
Mailing Address - Fax:505-286-2244
Practice Address - Street 1:1917 OLD ROUTE 66, EDGEWOOD PLAZA
Practice Address - Street 2:SUITE D-1
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-286-2020
Practice Address - Fax:505-286-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP1928Medicaid
NM1083450001Medicare NSC
NM400-84-8686Medicare ID - Type Unspecified
NMU56695Medicare UPIN