Healthcare Provider Details

I. General information

NPI: 1003665951
Provider Name (Legal Business Name): MIRAVISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/14/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#49 CALLE BLADORIOTY
COAMO PR
00769
US

IV. Provider business mailing address

109 CALLE REGENCIA
COAMO PR
00769-9814
US

V. Phone/Fax

Practice location:
  • Phone: 787-824-1934
  • Fax:
Mailing address:
  • Phone: 787-824-1934
  • 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: NAHIR E. SOTO
Title or Position: PRESIDENT/OWNER
Credential: OD
Phone: 787-406-3562