1942435094 NPI number — PPL MEDICAL CSP

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 1942435094 NPI number — PPL MEDICAL CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PPL MEDICAL CSP
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:
1942435094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 GRAND BULEVARD PASEOS
Provider Second Line Business Mailing Address:
SUITE 112 MSC 333
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00926-5955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-779-0484
Provider Business Mailing Address Fax Number:
787-779-3065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
68 SANTA CRUZ ST.
Provider Second Line Business Practice Location Address:
SUITE 405
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00961-7036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-779-0484
Provider Business Practice Location Address Fax Number:
787-779-3065
Provider Enumeration Date:
05/19/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
DOMINGO
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-779-0484

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  9828 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 9686 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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