Provider Demographics
NPI:1447585856
Name:CENTRO DIVA, INC
Entity Type:Organization
Organization Name:CENTRO DIVA, INC
Other - Org Name:CENTRO DIVA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIC SERVICES DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIRSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:QUINONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-812-3518
Mailing Address - Street 1:2830 AVE LAS AMERICAS
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-2100
Mailing Address - Country:US
Mailing Address - Phone:787-812-3518
Mailing Address - Fax:787-812-3749
Practice Address - Street 1:2830 AVE LAS AMERICAS
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2100
Practice Address - Country:US
Practice Address - Phone:787-812-3518
Practice Address - Fax:787-812-3749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-03
Last Update Date:2009-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR88152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty