Provider Demographics
NPI:1316317555
Name:KCM OPTICAL INC EYE CENTER BOUTIQUE
Entity type:Organization
Organization Name:KCM OPTICAL INC EYE CENTER BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OTHONIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:SR
Authorized Official - Credentials:O
Authorized Official - Phone:787-344-6192
Mailing Address - Street 1:600 CALLE TURIN
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-3604
Mailing Address - Country:US
Mailing Address - Phone:787-884-5924
Mailing Address - Fax:787-854-4407
Practice Address - Street 1:119 TRIGAL PLZ STE 4
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674-5518
Practice Address - Country:US
Practice Address - Phone:787-884-5924
Practice Address - Fax:787-854-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2015055550PUS076357332H00000X
PR06222780019332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier