Provider Demographics
NPI:1689973778
Name:E C BOUTIQUE CORP
Entity Type:Organization
Organization Name:E C BOUTIQUE CORP
Other - Org Name:EYE CENTER BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:D
Authorized Official - Last Name:SALIB FRAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-780-4444
Mailing Address - Street 1:90 PARQUE MEDICI
Mailing Address - Street 2:URB PASEO DEL PARQUE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6514
Mailing Address - Country:US
Mailing Address - Phone:787-780-4444
Mailing Address - Fax:787-780-4444
Practice Address - Street 1:501 AVE WEST MAIN SUITE 1215
Practice Address - Street 2:PLAZA DEL SOL
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-3867
Practice Address - Country:US
Practice Address - Phone:787-780-4444
Practice Address - Fax:787-780-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR135152W00000X
261Q00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center