1083977920 NPI number — PUERTO RICO RENAL HEALTH & RESEARCH

Table of content: (NPI 1083977920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083977920 NPI number — PUERTO RICO RENAL HEALTH & RESEARCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUERTO RICO RENAL HEALTH & RESEARCH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CKD -PONCE
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083977920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
AVE.TITO CASTRO 609
Provider Second Line Business Mailing Address:
SUITE 102 PBM 380
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00716-2232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-710-2532
Provider Business Mailing Address Fax Number:
787-843-5252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 AVE.TITO CASTRO
Provider Second Line Business Practice Location Address:
SUITE 102 PBM 380
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00716-0200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-710-2532
Provider Business Practice Location Address Fax Number:
787-843-5252
Provider Enumeration Date:
06/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ORTIZ
Authorized Official First Name:
ROSARIO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRIMARY NURSE
Authorized Official Telephone Number:
787-710-2532

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  1041C0700X , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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