=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679208466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE SPECIALIST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2022
-----------------------------------------------------
Last Update Date | 08/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE 5A MARGINAL K1 URB VILLA REAL
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-858-2624
-----------------------------------------------------
Fax | 939-440-9369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CALLE 5A MARGINAL K1 URB VILLA REAL
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-858-2624
-----------------------------------------------------
Fax | 939-440-9369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTE Y DUENO
-----------------------------------------------------
Name | MR. HECTOR SANCHEZ MALDONADO SR.
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 787-858-2624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------