Provider Demographics
NPI:1154581924
Name:BUENA VISTA OPTICAL,INC
Entity type:Organization
Organization Name:BUENA VISTA OPTICAL,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AWILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-778-8308
Mailing Address - Street 1:CARR #2 DRIVE IN PLAZA 2135
Mailing Address - Street 2:SUITE 65
Mailing Address - City:BAYAMON
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00959
Mailing Address - Country:UM
Mailing Address - Phone:787-778-8308
Mailing Address - Fax:787-778-8309
Practice Address - Street 1:2135 CARR 2 # IN
Practice Address - Street 2:SUITE 65
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-5219
Practice Address - Country:US
Practice Address - Phone:787-778-8308
Practice Address - Fax:787-778-8309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-14
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR185152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty