Provider Demographics
NPI:1255463584
Name:MILLENNIUM VISION CENTER PSC
Entity type:Organization
Organization Name:MILLENNIUM VISION CENTER PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDISON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-276-3435
Mailing Address - Street 1:PEARLE VISION
Mailing Address - Street 2:5829 PLAZA ESCORIAL SUITE 105
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-276-3435
Mailing Address - Fax:787-276-4835
Practice Address - Street 1:PEARLE VISION
Practice Address - Street 2:5829 PLAZA ESCORIAL SUITE 105
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987
Practice Address - Country:US
Practice Address - Phone:787-276-3435
Practice Address - Fax:787-276-4835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR55446Medicare UPIN
PR31355Medicare UPIN
PR00079Medicare UPIN
PR215265Medicare UPIN
PR=========Medicare UPIN