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General NPI Number Information
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NPI Number | 1083613988
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Entity Type | Organization
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Legal Business Name | WESTERN OPTICAL OUTLET, INC
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Dates
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Enumeration Date | 07/21/2005
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 164 CARR 2 PLAZA MONSERRATE 1 LOCAL 1
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City | HORMIGUEROS
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State | PR
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Zip | 00660-1400
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Country | US
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Telephone | 787-849-0303
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Fax | 787-849-0302
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Provider Business Mailing Address
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Address Line | PO BOX 30
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City | HORMIGUEROS
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State | PR
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Zip | 00660-0030
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Country | US
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Telephone | 787-849-0303
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Fax | 787-849-0302
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LIZA COLON
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Credential | OD
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Telephone | 787-849-0303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 497
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License Number State | PR
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