MEDICARE: VISTA-CLINICA VISUAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WV0400X	Vision Therapy Optometrist

General Provider Information

NPI Number	:	1366747198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA-CLINICA VISUAL

Provider Business Mailing Address
First Line	:	PLAZA SAN CRISTOBAL OFFICE PARK # 2003
Second Line	:	SUITE 102
City	:	COTO LAUREL
State	:	PR
Zip	:	00780
Country	:	US
Telephone Number	:	787-840-0303
Fax Number	:

Provider Business Practice Location Address
First Line	:	PLAZA SAN CRISTOBAL OFFICE PARK # 2003
Second Line	:	SUITE 102
City	:	COTO LAUREL
State	:	PR
Zip	:	00780
Country	:	US
Telephone Number	:	787-840-0303
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NIVIANA A. YAMBO
Credential	:	OD
Telephone Number	:	787-840-0303

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	01/26/2011

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Directions to “VISTA-CLINICA VISUAL ” Practice Location

Language	Start Address	Practice Location

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