=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952312324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSULTORIO OPTOMETRICO DE SG, CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. ANGEL C PEREZ #2
-----------------------------------------------------
City | SAN GERMAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-892-1218
-----------------------------------------------------
Fax | 787-892-7480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 495
-----------------------------------------------------
City | SAN GERMAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00683-0495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-892-1218
-----------------------------------------------------
Fax | 787-892-7480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/PRESIDENT
-----------------------------------------------------
Name | DR. LUIS E MORA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 787-892-1218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 403-0029
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------