Healthcare Provider Details

I. General information

NPI: 1114231933
Provider Name (Legal Business Name): ISLABELLA VISION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3285 AVE MILITAR
ISABELA PR
00662-4091
US

IV. Provider business mailing address

PO BOX 1967
ISABELA PR
00662-1967
US

V. Phone/Fax

Practice location:
  • Phone: 787-830-5784
  • Fax: 787-830-2436
Mailing address:
  • Phone: 787-830-5784
  • Fax: 787-830-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number12791
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number12791
License Number StatePR

VIII. Authorized Official

Name: DR. WALTER FRANCISCO NIEVES
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 787-830-5784