Provider Demographics
NPI:1396087508
Name:NIEVES GONZALEZ, EDRICK
Entity type:Individual
Prefix:
First Name:EDRICK
Middle Name:
Last Name:NIEVES GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3294
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3294
Mailing Address - Country:US
Mailing Address - Phone:787-501-4333
Mailing Address - Fax:787-805-0288
Practice Address - Street 1:975 AVE HOSTOS
Practice Address - Street 2:SUITE 62
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1251
Practice Address - Country:US
Practice Address - Phone:787-832-5540
Practice Address - Fax:787-832-5540
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL155525156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician