1134168354 NPI number — DE DIEGO AMBULATORY CLINIC CORP

Table of content: (NPI 1134168354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134168354 NPI number — DE DIEGO AMBULATORY CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DE DIEGO AMBULATORY CLINIC CORP
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:
CDT SAN JUAN MEDICAL PLAZA
Provider Other Organization Name Type Code:
3
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:
1134168354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 AVE DE DIEGO
Provider Second Line Business Mailing Address:
CONDOMINIO SAN JUAN HEALTH CENTRE BOX 1
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00907-2300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-977-7575
Provider Business Mailing Address Fax Number:
787-977-7605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 AVE DE DIEGO
Provider Second Line Business Practice Location Address:
CONDOMINIO SAN JUAN HEALTH CENTRE BOX 1
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00907-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-977-7575
Provider Business Practice Location Address Fax Number:
787-977-7605
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEAUCHAMP
Authorized Official First Name:
PEDRO
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
787-977-7575

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X , with the licence number:  105 , 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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