Healthcare Provider Details

I. General information

NPI: 1508049172
Provider Name (Legal Business Name): OPTICAL GALLERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EXPRESSO TRUJILLO CARRT 181 KM 4.0 OPTICAL GALLERY ECONO MEGA 1
TRUJILLO ALTO PR
00976
US

IV. Provider business mailing address

URB SIERRA BAYAMON CALLE 73 BLQ 85#5
BAYAMON PR
00961
US

V. Phone/Fax

Practice location:
  • Phone: 787-293-0915
  • Fax:
Mailing address:
  • Phone: 787-293-0915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StatePR

VIII. Authorized Official

Name: MR. JAVIER OMAR VAZQUEZ
Title or Position: OPTICO
Credential:
Phone: 787-293-0915