=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629257910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICA SAN VICENTE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2007
-----------------------------------------------------
Last Update Date | 07/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 CALLE MAYOR ZAMORA BUILDING FIRST FLOOR
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-844-8175
-----------------------------------------------------
Fax | 787-259-4462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 CALLE MAYOR ZAMORA BUILDING FIRST FLOOR
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-844-8175
-----------------------------------------------------
Fax | 787-259-4462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | MISS MYRIAM M SANTIAGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-844-8175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 135
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------