1316317555 NPI number — KCM OPTICAL INC EYE CENTER BOUTIQUE

Table of content: (NPI 1316317555)

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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