Provider Demographics
NPI:1972072494
Name:BUENA VISTA VISION CLUB, INC
Entity Type:Organization
Organization Name:BUENA VISTA VISION CLUB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIETA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-713-8170
Mailing Address - Street 1:16328 SW 43RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5328
Mailing Address - Country:US
Mailing Address - Phone:305-713-8170
Mailing Address - Fax:
Practice Address - Street 1:13780 SW 26TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6302
Practice Address - Country:US
Practice Address - Phone:305-439-2015
Practice Address - Fax:305-675-0443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty