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General NPI Number Information
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NPI Number | 1881224673
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Entity Type | Organization
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Legal Business Name | DEO PR RETAIL 1 LLC
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Dates
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Enumeration Date | 01/21/2020
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | AVENIDA DE DIEGO 310 PLAZA DE DIEGO LOCAL 102B
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City | SAN JUAN
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State | PR
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Zip | 00909
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Country | US
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Telephone | 787-776-8570
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Fax |
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Provider Business Mailing Address
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Address Line | 162 MONTAGUE ST APT 2
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City | BROOKLYN
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State | NY
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Zip | 11201-3506
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Country | US
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Telephone | 646-512-0313
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Fax |
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Authorized Official
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Title or Position | DIR. OF. OPERATIONS
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Name | MR. GUSTAVO ANDRES GAUTREN
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Credential |
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Telephone | 782-429-6724
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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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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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