Healthcare Provider Details

I. General information

NPI: 1972072494
Provider Name (Legal Business Name): BUENA VISTA VISION CLUB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13780 SW 26TH ST STE 201
MIAMI FL
33175-6302
US

IV. Provider business mailing address

16328 SW 43RD TER
MIAMI FL
33185-5328
US

V. Phone/Fax

Practice location:
  • Phone: 305-439-2015
  • Fax: 305-675-0443
Mailing address:
  • Phone: 305-713-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. LIETA DIAZ PADRON
Title or Position: OWNER
Credential: OD
Phone: 305-713-8170