Provider Demographics
NPI:1881683019
Name:MAYAGUEZ OPTICAL LAB
Entity Type:Organization
Organization Name:MAYAGUEZ OPTICAL LAB
Other - Org Name:SEARS OPTICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:787-834-2492
Mailing Address - Street 1:CALLE PERAL #14
Mailing Address - Street 2:EDIFICIO LA PALMA OFICINA 1A
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4913
Mailing Address - Country:US
Mailing Address - Phone:787-834-2492
Mailing Address - Fax:787-265-2190
Practice Address - Street 1:CALLE PERAL #14
Practice Address - Street 2:EDIFICIO LA PALMA OFICINA 1A
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4913
Practice Address - Country:US
Practice Address - Phone:787-834-2492
Practice Address - Fax:787-265-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty