1104030972 NPI number — NUCLEAR RADIOLOGY, CSP

Table of content: (NPI 1104030972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104030972 NPI number — NUCLEAR RADIOLOGY, CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NUCLEAR RADIOLOGY, CSP
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:
Provider Other Organization Name Type Code:
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:
1104030972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 GRAN PASEOS BULEVAR
Provider Second Line Business Mailing Address:
SUITE 112-137
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00926-5905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-474-8878
Provider Business Mailing Address Fax Number:
787-771-7445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HOSP AUXILIO MUTUO, 715 AVE PONCE DE LEON, PDA 37 1/2
Provider Second Line Business Practice Location Address:
EDIF NINO DIVINO JESUS, CENTRO IMAGENES DE LA MUJER
Provider Business Practice Location Address City Name:
HATO REY
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-474-8878
Provider Business Practice Location Address Fax Number:
787-771-7445
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAQUER
Authorized Official First Name:
RAFAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-474-8878

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: EC962A . This is a "PTAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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