Provider Demographics
NPI:1316100225
Name:RUIDOSO NATIONAL OPTICAL CENTER
Entity type:Organization
Organization Name:RUIDOSO NATIONAL OPTICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-378-7148
Mailing Address - Street 1:301 SAN MATEO BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2919
Mailing Address - Country:US
Mailing Address - Phone:505-378-7148
Mailing Address - Fax:505-378-1117
Practice Address - Street 1:1800 HIGHWAY 70 WEST
Practice Address - Street 2:
Practice Address - City:RUIDOSO DOWNS
Practice Address - State:NM
Practice Address - Zip Code:88346
Practice Address - Country:US
Practice Address - Phone:505-255-9410
Practice Address - Fax:505-255-9875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1134113541OtherDOCTOR INDIVIDUAL NPI
NM48374016Medicaid
NM341405910Medicare PIN
NM1134113541OtherDOCTOR INDIVIDUAL NPI