Healthcare Provider Details

I. General information

NPI: 1063632305
Provider Name (Legal Business Name): SERVICIOS OPTOMETRICOS CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. #2, EDIFICIO B , MULTIPLAZA PR SUITE #6 BO. CARACOL, KM. 143.3
ANASCO PR
00610
US

IV. Provider business mailing address

PO BOX 628
MAYAGUEZ PR
00681-0628
US

V. Phone/Fax

Practice location:
  • Phone: 787-826-6540
  • Fax: 787-826-6520
Mailing address:
  • Phone: 787-826-6540
  • Fax: 787-826-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number160
License Number StatePR

VIII. Authorized Official

Name: DR. ERNESTO SEPULVEDA
Title or Position: OWNER
Credential: O.D.
Phone: 787-826-6540