Provider Demographics
NPI:1447427638
Name:CLASSIC EYEWEAR, INC
Entity type:Organization
Organization Name:CLASSIC EYEWEAR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-326-2020
Mailing Address - Street 1:113 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6419
Mailing Address - Country:US
Mailing Address - Phone:505-326-2020
Mailing Address - Fax:505-327-5530
Practice Address - Street 1:113 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6419
Practice Address - Country:US
Practice Address - Phone:505-326-2020
Practice Address - Fax:505-327-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM437156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP2124Medicaid
NMU51912Medicare UPIN
NM0980580001Medicare NSC