=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922557578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESIGNER EYES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2016
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 MALL OF SAN JUAN STORE 140
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-490-0085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 MALL OF SAN JUAN BLVD STORE 140
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-490-0085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANCE MANAGER/ OPTICIAN
-----------------------------------------------------
Name | ANIBAL BAEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 939-246-1079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------