Basic Information
| Provider Information | |||||||||
| NPI: | 1750713566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1337 | ||||||||
| Address2: | DEPT 18 (EYE CLINIC) | ||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873051337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221397 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 E NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0002990 | CO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.