Provider Demographics
NPI:1285768069
Name:CLINICA VISUAL DE GUAYAMA
Entity type:Organization
Organization Name:CLINICA VISUAL DE GUAYAMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUNDO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-864-7938
Mailing Address - Street 1:42 PALMER
Mailing Address - Street 2:SUR URB CARIOCA
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00784
Mailing Address - Country:US
Mailing Address - Phone:787-864-7938
Mailing Address - Fax:
Practice Address - Street 1:PALMER SUR 42
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-864-7938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR058058Medicare UPIN