1467736702 NPI number — THE PALMS INTERVENTIONAL PAIN CLINIC, PSC

Table of content: (NPI 1467736702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467736702 NPI number — THE PALMS INTERVENTIONAL PAIN CLINIC, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PALMS INTERVENTIONAL PAIN CLINIC, PSC
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:
THE PALMS CLINIC
Provider Other Organization Name Type Code:
5
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:
1467736702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
URB. VALLE ARRIBA HEIGHTS
Provider Second Line Business Mailing Address:
ST. 110 BH 2
Provider Business Mailing Address City Name:
CAROLINA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-200-0350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 167 # INT839
Provider Second Line Business Practice Location Address:
SECTOR LA ALDEA
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00961-4477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-200-0350
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
787-200-0350

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  16381 , 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)

  • Identifier: CY164A . This is a "PTAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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