Healthcare Provider Details

I. General information

NPI: 1578170932
Provider Name (Legal Business Name): ECB HUMACAO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PALMA REAL SHOPPING CENTER LOCAL 2
HUMACAO PR
00791
US

IV. Provider business mailing address

PALMA REAL SHOPPING CENTER LOCAL 2
HUMACAO PR
00791
US

V. Phone/Fax

Practice location:
  • Phone: 787-850-5222
  • Fax:
Mailing address:
  • Phone: 787-850-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: GABRIEL SANTOS DELGADO
Title or Position: DELEGADO OFICIAL
Credential:
Phone: 787-239-0468