Healthcare Provider Details

I. General information

NPI: 1295160125
Provider Name (Legal Business Name): URBAN OPTIC SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281A CALLE CLEMSON UNIVERSITY GARDENS
SAN JUAN PR
00927-4127
US

IV. Provider business mailing address

CLEMSON 281-A UNIVERSITY GARDENS
SAN JUAN PR
00927-4020
US

V. Phone/Fax

Practice location:
  • Phone: 787-502-4910
  • Fax:
Mailing address:
  • Phone: 787-502-4910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. WANDA SANGIOVANNI
Title or Position: PRESIDENT
Credential: O.D.
Phone: 787-502-4910