=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528843059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYESTHETIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2023
-----------------------------------------------------
Last Update Date | 08/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PLAZA LAS PIEDRAS SHOPPING CENTER LOCAL G2
-----------------------------------------------------
City | LAS PIEDRAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-642-0108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | URB TERRALINDA CALLE BARCELONA 21
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-642-0108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. NORA E ALCOCER RODRIGUEZ
-----------------------------------------------------
Credential | MBR
-----------------------------------------------------
Telephone | 939-642-0108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------