Healthcare Provider Details

I. General information

NPI: 1821171109
Provider Name (Legal Business Name): BOULEVARD VISUAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. LEVITTOWN LAKES EE-10 CALLE JOSE S ALEGRIA
TOA BAJA PR
00949-2718
US

IV. Provider business mailing address

PO BOX 50707
TOA BAJA PR
00950-0707
US

V. Phone/Fax

Practice location:
  • Phone: 787-261-5333
  • Fax: 787-261-5333
Mailing address:
  • Phone: 787-261-5333
  • Fax: 787-261-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number163611
License Number StatePR

VIII. Authorized Official

Name: MR. JOSE ANTONIO COTTO
Title or Position: PRESIDENTE
Credential: O.D.
Phone: 787-261-5333