Provider Demographics
NPI:1750822573
Name:VISION OUTLET LLC
Entity type:Organization
Organization Name:VISION OUTLET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOMEZ LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-852-2470
Mailing Address - Street 1:5 CALLE DUFRESNE E
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-3605
Mailing Address - Country:US
Mailing Address - Phone:787-852-2470
Mailing Address - Fax:787-285-8093
Practice Address - Street 1:216 VILLA UNIVERSITARIA
Practice Address - Street 2:VILLA STATION
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3605
Practice Address - Country:US
Practice Address - Phone:787-852-2470
Practice Address - Fax:787-285-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR392241261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service