Provider Demographics
NPI:1508049172
Name:OPTICAL GALLERY
Entity Type:Organization
Organization Name:OPTICAL GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:OMAR
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-293-0915
Mailing Address - Street 1:URB SIERRA BAYAMON
Mailing Address - Street 2:CALLE 73 BLQ 85#5
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-293-0915
Mailing Address - Fax:
Practice Address - Street 1:EXPRESSO TRUJILLO CARRT 181 KM 4.0
Practice Address - Street 2:OPTICAL GALLERY ECONO MEGA 1
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976
Practice Address - Country:US
Practice Address - Phone:787-293-0915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6-2002Medicaid