Healthcare Provider Details

I. General information

NPI: 1508339722
Provider Name (Legal Business Name): VISTA CLINICA VISUAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 CARR 506 STE 101
COTO LAUREL PR
00780-2948
US

IV. Provider business mailing address

223 CALLE ISABEL
COTO LAUREL PR
00780-2601
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-4646
  • Fax: 787-840-4646
Mailing address:
  • Phone: 787-840-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. NIVIANA A YAMBO-MERCADO
Title or Position: PRESIDENT
Credential: OD
Phone: 787-840-4646