Provider Demographics
NPI:1871240382
Name:RODMART OPTICAL INC
Entity Type:Organization
Organization Name:RODMART OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-264-3848
Mailing Address - Street 1:162 AVE UNIV INTERAMERICANA
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-4330
Mailing Address - Country:US
Mailing Address - Phone:787-264-3848
Mailing Address - Fax:787-264-3848
Practice Address - Street 1:162 AVE UNIV INTERAMERICANA
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-4330
Practice Address - Country:US
Practice Address - Phone:787-264-3848
Practice Address - Fax:787-264-3848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RODMART OPTICAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1356565493Medicaid