Provider Demographics
NPI:1679052773
Name:CONDADO OPTICAL, LLC
Entity Type:Organization
Organization Name:CONDADO OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NILSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:VILAR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-268-6099
Mailing Address - Street 1:PO BOX 1995
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-1995
Mailing Address - Country:US
Mailing Address - Phone:787-636-8232
Mailing Address - Fax:
Practice Address - Street 1:1452 AVE ASHFORD
Practice Address - Street 2:COND ADA LIGIA 1A
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-636-8232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty