Provider Demographics
NPI:1508339722
Name:VISTA CLINICA VISUAL, LLC
Entity Type:Organization
Organization Name:VISTA CLINICA VISUAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIVIANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:YAMBO-MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-840-4646
Mailing Address - Street 1:223 CALLE ISABEL
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-2601
Mailing Address - Country:US
Mailing Address - Phone:787-840-4646
Mailing Address - Fax:
Practice Address - Street 1:1718 CARR 506 STE 101
Practice Address - Street 2:
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780-2948
Practice Address - Country:US
Practice Address - Phone:787-840-4646
Practice Address - Fax:787-840-4646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-10
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty