1205803210 NPI number — CLINICA DE MEDICINA DEPORTIVA DEL CARIBE INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205803210 NPI number — CLINICA DE MEDICINA DEPORTIVA DEL CARIBE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICA DE MEDICINA DEPORTIVA DEL CARIBE INC.
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:
1205803210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEL PARQUE STREET 110 BALMORAL BLDG
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-721-4643
Provider Business Mailing Address Fax Number:
787-723-8664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 CALLE DEL PARQUE
Provider Second Line Business Practice Location Address:
BALMORAL BLDG 1ST FLOOR
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00911-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-723-4857
Provider Business Practice Location Address Fax Number:
787-723-8664
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VELASCO
Authorized Official First Name:
EDWIN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
787-721-4643

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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