Provider Demographics
NPI:1518580943
Name:MY OPTICAL FACTORY LLC
Entity Type:Organization
Organization Name:MY OPTICAL FACTORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:VILLALOBOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-860-4090
Mailing Address - Street 1:PO BOX 1400
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-1400
Mailing Address - Country:US
Mailing Address - Phone:787-860-4090
Mailing Address - Fax:
Practice Address - Street 1:#61 CALLE GARRIDO MORALES W
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-860-4090
Practice Address - Fax:787-863-5515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRJM124Medicaid