Provider Demographics
NPI:1821171109
Name:BOULEVARD VISUAL CLINIC
Entity Type:Organization
Organization Name:BOULEVARD VISUAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:COTTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-261-5333
Mailing Address - Street 1:PO BOX 50707
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-0707
Mailing Address - Country:US
Mailing Address - Phone:787-261-5333
Mailing Address - Fax:787-261-5333
Practice Address - Street 1:URB. LEVITTOWN LAKES EE-10
Practice Address - Street 2:CALLE JOSE S ALEGRIA
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949-2718
Practice Address - Country:US
Practice Address - Phone:787-261-5333
Practice Address - Fax:787-261-5333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR163611332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherMEDICAL CARD SYSTEM, INC.