Provider Demographics
NPI:1538343355
Name:TERRY T MARQUARDT
Entity type:Organization
Organization Name:TERRY T MARQUARDT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:MARQUARDT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:575-437-7783
Mailing Address - Street 1:903 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6919
Mailing Address - Country:US
Mailing Address - Phone:575-437-7783
Mailing Address - Fax:575-439-0615
Practice Address - Street 1:903 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6919
Practice Address - Country:US
Practice Address - Phone:575-437-7783
Practice Address - Fax:575-439-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM233332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0659340001Medicare NSC