Healthcare Provider Details

I. General information

NPI: 1760465066
Provider Name (Legal Business Name): M&M OPTICAL SHOP CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 AVE J T PINERO ALTAMIRA XTRA SHOPPING CENTER
SAN JUAN PR
00921-1102
US

IV. Provider business mailing address

PO BOX 7891 PMB 333
GUAYNABO PR
00970-7891
US

V. Phone/Fax

Practice location:
  • Phone: 787-782-2175
  • Fax: 787-782-2175
Mailing address:
  • Phone: 787-782-2175
  • Fax: 787-782-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: FRANCIS D MEDINA
Title or Position: OWNER
Credential:
Phone: 787-625-9144