Provider Demographics
NPI:1255965794
Name:OPTIC SHOP
Entity type:Organization
Organization Name:OPTIC SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:VICENTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALCARAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-758-2404
Mailing Address - Street 1:PO BOX 191168
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-1168
Mailing Address - Country:US
Mailing Address - Phone:787-758-2404
Mailing Address - Fax:787-764-4227
Practice Address - Street 1:572 CALLE CESAR GONZALEZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3738
Practice Address - Country:US
Practice Address - Phone:787-758-2404
Practice Address - Fax:787-764-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier