=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114648128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENABE VISUAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2022
-----------------------------------------------------
Last Update Date | 09/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12-30 BOULEVARD DR # DRIVEC
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00959-6656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-637-1464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 194483
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00919-4483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARMEN BENABE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 787-637-1464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------