Healthcare Provider Details

I. General information

NPI: 1831880178
Provider Name (Legal Business Name): CORDOBESA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2092 CARR 633 BO BARAHONA
MOROVIS PR
00687
US

IV. Provider business mailing address

PO BOX 190399
SAN JUAN PR
00919-0399
US

V. Phone/Fax

Practice location:
  • Phone: 787-369-2400
  • 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: MARIA D CAMACHO PEINADO
Title or Position: PRESIDENT
Credential:
Phone: 787-369-2400