Provider Demographics
NPI:1679962906
Name:EYE CENTER BOUTIQUE INC
Entity type:Organization
Organization Name:EYE CENTER BOUTIQUE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORDERO-VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-617-8850
Mailing Address - Street 1:83 UNION ST. SUITE 129
Mailing Address - Street 2:GALERIAS PONCENAS MALL
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-3686
Mailing Address - Country:US
Mailing Address - Phone:787-643-9020
Mailing Address - Fax:
Practice Address - Street 1:MAYGUEZ MALL
Practice Address - Street 2:LOCAL #50
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1251
Practice Address - Country:US
Practice Address - Phone:787-643-9250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty