1609190610 NPI number — IMI OF SAN JUAN

Table of content: (NPI 1609190610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609190610 NPI number — IMI OF SAN JUAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMI OF SAN JUAN
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:
6
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:
1609190610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1448 AVE FERNANDEZ JUNCOS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTURCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00909-2655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-721-7776
Provider Business Mailing Address Fax Number:
787-721-7774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVENUE MONSERRATE #AC8
Provider Second Line Business Practice Location Address:
VALLE ARRIBA HEIGHTS
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00985-5444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-757-5985
Provider Business Practice Location Address Fax Number:
787-757-6190
Provider Enumeration Date:
03/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SOUFFRONT
Authorized Official First Name:
NIVIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CENTER DIRECTOR
Authorized Official Telephone Number:
787-757-5985

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  52-25390-01 , 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: 52-25390-01 . This is a "NRC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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