Healthcare Provider Details

I. General information

NPI: 1467363036
Provider Name (Legal Business Name): PREMIUM VISION HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZA PRADOS DEL SUR 3-B3 INTERSECCION CARR 143 Y 542
SANTA ISABEL PR
00757
US

IV. Provider business mailing address

PLAZA FAJARDO CARR 3 SUITE 125
FAJARDO PR
00738
US

V. Phone/Fax

Practice location:
  • Phone: 787-558-5505
  • Fax:
Mailing address:
  • Phone: 787-558-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GABRIEL SANTOS DELGADO
Title or Position: OPTOMETRIST
Credential: OD
Phone: 787-558-5501