Healthcare Provider Details

I. General information

NPI: 1134742067
Provider Name (Legal Business Name): DEO PR RETAIL 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 10/10/2023
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 PR-52
CAGUAS PR
00725
US

IV. Provider business mailing address

2019 E 3RD ST
BROOKLYN NY
11223-2946
US

V. Phone/Fax

Practice location:
  • Phone: 646-512-0313
  • Fax:
Mailing address:
  • Phone: 646-512-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. GUSTAVO ANDRES GAUTIER
Title or Position: DIR. OF OPERATIONS
Credential:
Phone: 787-429-6724