Provider Demographics
NPI:1972653673
Name:OHI OF PUERTO RICO, LLC
Entity Type:Organization
Organization Name:OHI OF PUERTO RICO, LLC
Other - Org Name:PEARLE VISION 8755
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR; ASSIGNMENT OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-925-1851
Mailing Address - Street 1:275 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3554
Mailing Address - Country:US
Mailing Address - Phone:917-716-7666
Mailing Address - Fax:
Practice Address - Street 1:REXVILLE TOWN CTR
Practice Address - Street 2:BLDG A4 RD #167 K.M. 17.6
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-9212
Practice Address - Country:US
Practice Address - Phone:787-279-8137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0132600600Medicare NSC