1063260040 NPI number — SPINE CLINIC PHYSICIAN OF PUERTO RICO

Table of content: (NPI 1063260040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063260040 NPI number — SPINE CLINIC PHYSICIAN OF PUERTO RICO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE CLINIC PHYSICIAN OF PUERTO RICO
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:
1063260040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CENTRO INTERNACIONAL DE MERCADEO, TORRE 1
Provider Second Line Business Mailing Address:
100 CARR. 165 SUITE 606
Provider Business Mailing Address City Name:
GUAYNABO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00968-8048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
939-225-7972
Provider Business Mailing Address Fax Number:
939-225-7974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CENTRO INTERNACIONAL DE MERCADEO, TORRE 1
Provider Second Line Business Practice Location Address:
100 CARR. 165 SUITE 606
Provider Business Practice Location Address City Name:
GUAYNABO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00968-8048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
939-225-7972
Provider Business Practice Location Address Fax Number:
939-225-7974
Provider Enumeration Date:
05/07/2024

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
ALBERTO
Authorized Official Middle Name:
JOSUE
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
939-225-7972

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1528705472 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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