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General NPI Number Information
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NPI Number | 1134742067
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Entity Type | Organization
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Legal Business Name | DEO PR RETAIL 2 LLC
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Dates
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Enumeration Date | 05/27/2020
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 270 PR-52
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City | CAGUAS
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State | PR
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Zip | 00725
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Country | US
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Telephone | 646-512-0313
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Fax |
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Provider Business Mailing Address
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Address Line | 2019 E 3RD ST
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City | BROOKLYN
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State | NY
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Zip | 11223-2946
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Country | US
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Telephone | 646-512-0313
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Fax |
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Authorized Official
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Title or Position | DIR. OF OPERATIONS
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Name | MR. GUSTAVO ANDRES GAUTIER
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Credential |
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Telephone | 787-429-6724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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