1316317555 NPI number — KCM OPTICAL INC EYE CENTER BOUTIQUE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316317555 NPI number — KCM OPTICAL INC EYE CENTER BOUTIQUE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KCM OPTICAL INC EYE CENTER BOUTIQUE
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:
Provider Other Organization Name Type Code:
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:
1316317555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 CALLE TURIN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VEGA BAJA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00693-3604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-884-5924
Provider Business Mailing Address Fax Number:
787-854-4407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 TRIGAL PLZ STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANATI
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00674-5518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-884-5924
Provider Business Practice Location Address Fax Number:
787-854-4407
Provider Enumeration Date:
09/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
OTHONIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-344-6192

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  2015055550PUS076357 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 06222780019 , 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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