1831505841 NPI number — EASTERN RETINA CONSULTANTS OF PUERTO RICO, PSC

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 1831505841 NPI number — EASTERN RETINA CONSULTANTS OF PUERTO RICO, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN RETINA CONSULTANTS OF PUERTO RICO, PSC
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:
1831505841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#15 AVE. PADRE RIVERA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMACAO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00791
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-852-6825
Provider Business Mailing Address Fax Number:
787-850-5005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
#15 AVE. PADRE RIVERA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMACAO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-852-6825
Provider Business Practice Location Address Fax Number:
787-850-5005
Provider Enumeration Date:
07/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BENITEZ BAJANDAS
Authorized Official First Name:
GABRIEL
Authorized Official Middle Name:
ALBERTO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-697-1171

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  339876 , 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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