Provider Demographics
NPI:1881224673
Name:DEO PR RETAIL 1 LLC
Entity type:Organization
Organization Name:DEO PR RETAIL 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR. OF. OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:ANDRES
Authorized Official - Last Name:GAUTREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:782-429-6724
Mailing Address - Street 1:162 MONTAGUE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3506
Mailing Address - Country:US
Mailing Address - Phone:646-512-0313
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA DE DIEGO
Practice Address - Street 2:310 PLAZA DE DIEGO LOCAL 102B
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-776-8570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHALEM CONSUMER BRANDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-21
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1578111043Medicaid