Provider Demographics
NPI:1093450678
Name:OPTICAL ILLUSION
Entity Type:Organization
Organization Name:OPTICAL ILLUSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORAINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRANCO LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:1439 OP
Authorized Official - Phone:787-848-2394
Mailing Address - Street 1:CALLE CENTRAL 85 LOCAL 1
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780
Mailing Address - Country:US
Mailing Address - Phone:939-273-1283
Mailing Address - Fax:
Practice Address - Street 1:CALLE CENTRAL 85 LOCAL 1
Practice Address - Street 2:
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-848-2394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-28
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty