Healthcare Provider Details

I. General information

NPI: 1669631305
Provider Name (Legal Business Name): CITY OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2008
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 CALLE ROBLES
SAN JUAN PR
00925-2919
US

IV. Provider business mailing address

485 BAYAMON LA CUMBRE
SAN JUAN PR
00926-2919
US

V. Phone/Fax

Practice location:
  • Phone: 787-766-9376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number397
License Number StatePR

VIII. Authorized Official

Name: DR. MARISOL RODRIGUEZ
Title or Position: OWNER
Credential: OPTOMETRIST
Phone: 787-766-9376