Organization
GOLDEN SKILLET, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN WILLIAM DIETERICHS (OWNER)
(505) 859-5934
Entity
Organization
Contact information
Practice address
703 CHRISTOPHER DR, BELEN, NM 87002-2617
(505) 864-7781
Mailing address
1606 JACK NICKLAUS DR, RIO COMMUNITIES, NM 87002-5925
(505) 859-5934
(505) 212-0766
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03582434004
NEW MEXICO CRS
NM
Enumeration date
08/08/2022
Last updated
08/08/2022
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