Healthcare Provider Details

I. General information

NPI: 1003942467
Provider Name (Legal Business Name): WALMART #2067
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAYAGUEZ MALL STATE RD # 2
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

975 AVE. HOSTOS SUITE 2100
MAYAGUEZ PR
00668-1252
US

V. Phone/Fax

Practice location:
  • Phone: 787-834-2280
  • Fax: 787-834-3020
Mailing address:
  • Phone: 787-834-2280
  • Fax: 787-834-3020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JORGE L HERNANDEZ
Title or Position: DIRECTOR OF SPECIALTY DIVISION
Credential:
Phone: 787-653-7777