Provider Demographics
NPI:1760699813
Name:VISUAL OUTLET & OPTICAL STORE
Entity Type:Organization
Organization Name:VISUAL OUTLET & OPTICAL STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-891-4400
Mailing Address - Street 1:153 AVE PEDRO ALBIZU CAMPOS
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-5724
Mailing Address - Country:US
Mailing Address - Phone:787-891-4400
Mailing Address - Fax:787-882-1059
Practice Address - Street 1:153 AVE PEDRO ALBIZU CAMPOS AVE.
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5724
Practice Address - Country:US
Practice Address - Phone:787-891-4400
Practice Address - Fax:787-882-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty