Provider Demographics
NPI:1215954011
Name:MIKELA D. KWAN, OPTOMETRIC SERVICES, LLC
Entity type:Organization
Organization Name:MIKELA D. KWAN, OPTOMETRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKELA
Authorized Official - Middle Name:DAWNA
Authorized Official - Last Name:KWAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-822-8387
Mailing Address - Street 1:6208 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1400
Mailing Address - Country:US
Mailing Address - Phone:505-822-8387
Mailing Address - Fax:
Practice Address - Street 1:6208 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1400
Practice Address - Country:US
Practice Address - Phone:505-822-8387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty