Provider Demographics
NPI:1114322963
Name:ADVANCE OPHTALMOLOGY GROUP PSC
Entity Type:Organization
Organization Name:ADVANCE OPHTALMOLOGY GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTALVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-878-2744
Mailing Address - Street 1:PO BOX 140819
Mailing Address - Street 2:AVE JOSE DE DIEGO 404
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-0819
Mailing Address - Country:US
Mailing Address - Phone:787-878-2758
Mailing Address - Fax:787-817-3531
Practice Address - Street 1:404 AVE DE DIEGO
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00614
Practice Address - Country:US
Practice Address - Phone:787-878-2744
Practice Address - Fax:787-817-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8647156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherEIN