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General NPI Number Information
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NPI Number | 1750092367
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Entity Type | Organization
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Legal Business Name | BRAIN & VISION BOUTIQUE
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Dates
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Enumeration Date | 12/06/2022
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Last Update Date | 12/20/2022
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Provider Practice Location Address
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Address Line | 701 AVE. PONCE DE LEON EDF CENTRO DE SEGUROS SUITE 108-B
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City | SAN JUAN
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State | PR
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Zip | 00907
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Country | US
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Telephone | 787-223-8752
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Fax |
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Provider Business Mailing Address
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Address Line | 78 CALLE CORALINA
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City | SAN JUAN
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State | PR
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Zip | 00926-9634
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Country | US
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Telephone | 787-210-6092
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | DR. JOVANNY ULLOA
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Credential | OD
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Telephone | 939-336-4584
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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