Healthcare Provider Details

I. General information

NPI: 1083395867
Provider Name (Legal Business Name): EYE CARE BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 129 KM 9.1
HATILLO PR
00659
US

IV. Provider business mailing address

HC 5 BOX 34600
HATILLO PR
00659-9798
US

V. Phone/Fax

Practice location:
  • Phone: 787-930-2035
  • Fax:
Mailing address:
  • Phone:
  • 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: ADIANNETTE GONZALEZ RODRIGUEZ
Title or Position: OWNER
Credential:
Phone: 787-930-2035