Provider Demographics
NPI:1154596633
Name:OPTICA ALTA VISION
Entity type:Organization
Organization Name:OPTICA ALTA VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-797-6978
Mailing Address - Street 1:200 CARR 829 STE 5
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-7945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR. 829 KM 2.7 BO. PINAS
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-797-6978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty