=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740525880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALBERT RIVERA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2012
-----------------------------------------------------
Last Update Date | 02/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 CALLE MUNOZ RIVERA CLINICA VISUAL VILLALBA
-----------------------------------------------------
City | VILLALBA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00766-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-847-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 CALLE MUNOZ RIVERA CLINICA VISUAL VILLALBA
-----------------------------------------------------
City | VILLALBA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00766-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-847-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 906
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------