Healthcare Provider Details

I. General information

NPI: 1720712565
Provider Name (Legal Business Name): PRO VISION OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 A CALLE DAMAS
SAN GERMAN PR
00683
US

IV. Provider business mailing address

PO BOX 851
MANATI PR
00674-0851
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-9300
  • Fax: 787-854-6639
Mailing address:
  • Phone: 787-854-9300
  • Fax: 787-854-6639

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: MR. WILSON J. MENDEZ LUGO
Title or Position: OWNER
Credential:
Phone: 787-854-9300