Provider Demographics
NPI:1083613988
Name:WESTERN OPTICAL OUTLET, INC
Entity Type:Organization
Organization Name:WESTERN OPTICAL OUTLET, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-849-0303
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-0030
Mailing Address - Country:US
Mailing Address - Phone:787-849-0303
Mailing Address - Fax:787-849-0302
Practice Address - Street 1:164 CARR 2
Practice Address - Street 2:PLAZA MONSERRATE 1 LOCAL 1
Practice Address - City:HORMIGUEROS
Practice Address - State:PR
Practice Address - Zip Code:00660-1400
Practice Address - Country:US
Practice Address - Phone:787-849-0303
Practice Address - Fax:787-849-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR497152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty