Provider Demographics
NPI:1144086562
Name:E C BOUTIQUE CORP
Entity type:Organization
Organization Name:E C BOUTIQUE CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:D
Authorized Official - Last Name:SALIB FRAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-507-5377
Mailing Address - Street 1:90 CALLE MEDICI
Mailing Address - Street 2:URB PASEO DEL PARQUE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-6514
Mailing Address - Country:US
Mailing Address - Phone:787-507-5377
Mailing Address - Fax:787-731-5642
Practice Address - Street 1:1000 THE MALL OF SJ BOULEVARD
Practice Address - Street 2:SUITE 118 URB VILLA OLIMPIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-4043
Practice Address - Country:US
Practice Address - Phone:787-507-5377
Practice Address - Fax:787-731-5642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-23
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center