1790239762 NPI number — PREMIER MEDICAL CNTR OF HUMACAO LLC

Table of content: (NPI 1790239762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790239762 NPI number — PREMIER MEDICAL CNTR OF HUMACAO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER MEDICAL CNTR OF HUMACAO 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:
1790239762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10319 JEFFERSON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-2730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-214-9352
Provider Business Mailing Address Fax Number:
225-214-9349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVE. BOULEVARD SUR, TORRE PISO 1
Provider Second Line Business Practice Location Address:
BOULEVARD DEL RIO OFFICE CENTER, BO. RIO ABAJO
Provider Business Practice Location Address City Name:
HUMACAO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00791-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-656-2727
Provider Business Practice Location Address Fax Number:
787-656-2732
Provider Enumeration Date:
08/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
VP, REV. CYCLE SERVICES
Authorized Official Telephone Number:
225-239-7190

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com