Provider Demographics
NPI:1750092367
Name:BRAIN & VISION BOUTIQUE
Entity type:Organization
Organization Name:BRAIN & VISION BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOVANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLOA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:939-336-4584
Mailing Address - Street 1:78 CALLE CORALINA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-9634
Mailing Address - Country:US
Mailing Address - Phone:787-210-6092
Mailing Address - Fax:
Practice Address - Street 1:701 AVE. PONCE DE LEON
Practice Address - Street 2:EDF CENTRO DE SEGUROS SUITE 108-B
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-223-8752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAIN & VISION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-06
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty