1265874689 NPI number — GRUPO FISIATRICO-DENTAL DEL ESTE, CORP.

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 1265874689 NPI number — GRUPO FISIATRICO-DENTAL DEL ESTE, CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRUPO FISIATRICO-DENTAL DEL ESTE, 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:
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:
1265874689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SAN FRANCISCO
Provider Second Line Business Mailing Address:
225 CALLE VIOLETA
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00927-6223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-887-1110
Provider Business Mailing Address Fax Number:
787-888-7008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
JARDINES DE RIO GRANDE
Provider Second Line Business Practice Location Address:
CALLE 54 BG-176
Provider Business Practice Location Address City Name:
RIO GRANDE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-887-1110
Provider Business Practice Location Address Fax Number:
787-888-7008
Provider Enumeration Date:
07/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-887-1110

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1780 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 10386 , 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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