1114488749 NPI number — TATIANA IVELISSE CARRAQUILLO ROSA CPTH

Table of content: TATIANA IVELISSE CARRAQUILLO ROSA CPTH (NPI 1114488749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114488749 NPI number — TATIANA IVELISSE CARRAQUILLO ROSA CPTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARRAQUILLO ROSA
Provider First Name:
TATIANA
Provider Middle Name:
IVELISSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPTH
Provider Gender Code:
F

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:
1114488749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 CALLE JOSE TOUS SOTO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LORENZO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-388-6209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BO CEIBA NORTE
Provider Second Line Business Practice Location Address:
CARR 31 KM 24.5
Provider Business Practice Location Address City Name:
JUNCOS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-705-2239
Provider Business Practice Location Address Fax Number:
888-580-6779
Provider Enumeration Date:
03/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183700000X , with the licence number:  12056 , 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: 6564767 . This is a "DRIVER'LICENCE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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