Provider Demographics
NPI:1487048443
Name:TIMES SQUARE OPTICAL LLC
Entity type:Organization
Organization Name:TIMES SQUARE OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, ABOC
Authorized Official - Phone:956-693-0899
Mailing Address - Street 1:7917 MCPHERSON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-2812
Mailing Address - Country:US
Mailing Address - Phone:956-284-0781
Mailing Address - Fax:
Practice Address - Street 1:7917 MCPHERSON RD STE 206
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-2812
Practice Address - Country:US
Practice Address - Phone:956-284-0781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
7379540001Medicare NSC