1215266564 NPI number — BROKEN BONE ORTHO 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 1215266564 NPI number — BROKEN BONE ORTHO CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROKEN BONE ORTHO 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:
1215266564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 366905
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00936-6905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-756-6999
Provider Business Mailing Address Fax Number:
787-765-7880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
369 CALLE DE DIEGO STE 202
Provider Second Line Business Practice Location Address:
TORRE SAN FRANCISCO
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00923-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-756-6999
Provider Business Practice Location Address Fax Number:
787-765-7880
Provider Enumeration Date:
12/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OTERO
Authorized Official First Name:
RAFAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-756-6999

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  4470 , 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)





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