Provider Demographics
NPI:1063632305
Name:SERVICIOS OPTOMETRICOS CSP
Entity Type:Organization
Organization Name:SERVICIOS OPTOMETRICOS CSP
Other - Org Name:CONSULTORIO OPTOMETRICO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:SEPULVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-826-6540
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0628
Mailing Address - Country:US
Mailing Address - Phone:787-826-6540
Mailing Address - Fax:787-826-6520
Practice Address - Street 1:CARR. #2, EDIFICIO B , MULTIPLAZA PR
Practice Address - Street 2:SUITE #6 BO. CARACOL, KM. 143.3
Practice Address - City:ANASCO
Practice Address - State:PR
Practice Address - Zip Code:00610
Practice Address - Country:US
Practice Address - Phone:787-826-6540
Practice Address - Fax:787-826-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5-8024Medicare ID - Type Unspecified
PRT26866Medicare UPIN