Provider Demographics
NPI:1841847142
Name:ECB HUMACAO LLC
Entity type:Organization
Organization Name:ECB HUMACAO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:787-239-0468
Mailing Address - Street 1:CENTRO COMERCIAL PLAZA FAJARDO LOCAL 125 CARR 3 KM 43.3
Mailing Address - Street 2:BARRIO QUEBRADA ABAJO
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-718-5767
Mailing Address - Fax:
Practice Address - Street 1:CENTRO COMERCIAL PLAZA FAJARDO LOCAL 125 CARR 3 KM 43.3
Practice Address - Street 2:BARRIO QUEBRADA ABAJO
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-718-5767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038044400Medicaid