Provider Demographics
NPI:1093910952
Name:EYE LAND OPTICAL INC
Entity Type:Organization
Organization Name:EYE LAND OPTICAL INC
Other - Org Name:CENTRO OFTALMOLOGICO LOPEZ Y OPTICA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-882-4189
Mailing Address - Street 1:PO BOX 250431
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00604-0431
Mailing Address - Country:US
Mailing Address - Phone:787-882-4189
Mailing Address - Fax:787-882-0562
Practice Address - Street 1:STREET 110 KM 0.3
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-882-4189
Practice Address - Fax:787-882-0562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14569156FC0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR263899563Medicaid