Provider Demographics
NPI:1124166293
Name:THE OPTICAL SHOP INC
Entity type:Organization
Organization Name:THE OPTICAL SHOP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FIDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ TORRES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:787-823-4545
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:PR
Mailing Address - Zip Code:00677-0464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 115 KM 11.6 BO. PUEBLO
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:PR
Practice Address - Zip Code:00677
Practice Address - Country:US
Practice Address - Phone:787-823-4545
Practice Address - Fax:787-823-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty