1174007470 NPI number — COSTA ESTE MEDICAL SERVICES LLC

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 1174007470 NPI number — COSTA ESTE MEDICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSTA ESTE MEDICAL SERVICES LLC
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:
1174007470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUQUILLO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00773-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-860-3700
Provider Business Mailing Address Fax Number:
787-860-3800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVE PRINCIPAL F4
Provider Second Line Business Practice Location Address:
URB BARALT
Provider Business Practice Location Address City Name:
FAJARDO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-860-3700
Provider Business Practice Location Address Fax Number:
787-860-3800
Provider Enumeration Date:
09/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
ISMARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-646-7769

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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