1790750529 NPI number — CDT GMSP, INC

Table of content: (NPI 1790750529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790750529 NPI number — CDT GMSP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CDT GMSP, 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:
LAB CDT GMSP
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:
1790750529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
B7 CALLE SANTA CRUZ
Provider Second Line Business Mailing Address:
AVE. SANTA CRUZ
Provider Business Mailing Address City Name:
BAYAMON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00961-6902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-780-9196
Provider Business Mailing Address Fax Number:
787-625-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
B7 CALLE SANTA CRUZ
Provider Second Line Business Practice Location Address:
AVE. SANTA CRUZ
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00961-6902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-780-9196
Provider Business Practice Location Address Fax Number:
787-625-6120
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZAYAS
Authorized Official First Name:
ILIA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
EXUCUTIVE DIRECTOR
Authorized Official Telephone Number:
787-780-9196

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  1028 , 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: 1790750529 . This is a "NPI" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 0039200 . This is a "MEDICARE PROVIDER" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 037546800 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40D0699278 . This is a "CLIA NUMBER" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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