1639246614 NPI number — MEDICOR HEALTHCARE INC

Table of content: (NPI 1639246614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639246614 NPI number — MEDICOR HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICOR HEALTHCARE INC
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:
1639246614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 70255
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:
00936-8255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-250-4468
Provider Business Mailing Address Fax Number:
866-930-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
69-2 AVENIDA WEST MAIN SIERRA BAYAMON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-787-5573
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DELGADO
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
787-787-5573

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  05-P-2071 , 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: 57166 . This is a "SSS PROVIDER NUMBER" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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