Provider Demographics
NPI:1316136443
Name:L VICTOR SANDOVAL, P.C.
Entity type:Organization
Organization Name:L VICTOR SANDOVAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:L VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:575-522-8334
Mailing Address - Street 1:700 S TELSHOR BLVD
Mailing Address - Street 2:STE #1534
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:575-522-8334
Mailing Address - Fax:575-522-1065
Practice Address - Street 1:700 S TELSHOR BLVD
Practice Address - Street 2:STE #1534
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8608
Practice Address - Country:US
Practice Address - Phone:575-522-8334
Practice Address - Fax:575-522-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2260152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99429268Medicaid
NM249603101Medicare PIN
NM99429268Medicaid