MEDICARE: OHI OF PUERTO RICO, LLC

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	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1679949473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHI OF PUERTO RICO, LLC

Provider Business Mailing Address
First Line	:	275 ROUTE 22
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3554
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	REXVILLE TOWN CTR BLDG A4
Second Line	:	RD #167 K.M. 17.6
City	:	BAYAMON
State	:	PR
Zip	:	00956-9212
Country	:	US
Telephone Number	:	787-279-8137
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	KAREN LEMER
Credential	:
Telephone Number	:	847-309-0098

Provider Enumeration Date	:	08/15/2015
Last Update Date	:	08/15/2015

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