Provider Demographics
NPI:1528443496
Name:WESTSIDE EYECARE
Entity type:Organization
Organization Name:WESTSIDE EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:RAEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-899-7473
Mailing Address - Street 1:5101 COORS BLVD N.W.
Mailing Address - Street 2:STE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1923
Mailing Address - Country:US
Mailing Address - Phone:505-899-7473
Mailing Address - Fax:505-899-4845
Practice Address - Street 1:5101 COORS BLVD N.W
Practice Address - Street 2:STE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1923
Practice Address - Country:US
Practice Address - Phone:505-899-7473
Practice Address - Fax:505-899-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty