1154581924 NPI number — BUENA VISTA OPTICAL,INC

Table of content: (NPI 1154581924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154581924 NPI number — BUENA VISTA OPTICAL,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUENA VISTA OPTICAL,INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PEARLE VISION DRIVE IN PLAZA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154581924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CARR #2 DRIVE IN PLAZA 2135
Provider Second Line Business Mailing Address:
SUITE 65
Provider Business Mailing Address City Name:
BAYAMON
Provider Business Mailing Address State Name:
PUERTO RICO
Provider Business Mailing Address Postal Code:
00959
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
787-778-8308
Provider Business Mailing Address Fax Number:
787-778-8309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2135 CARR 2 # IN
Provider Second Line Business Practice Location Address:
SUITE 65
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00959-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-778-8308
Provider Business Practice Location Address Fax Number:
787-778-8309
Provider Enumeration Date:
06/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
AWILDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-778-8308

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  185 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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