1891104188 NPI number — SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC

Table of content: (NPI 1891104188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891104188 NPI number — SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST OTO AND HEAD & NECK SURGERY,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:
1891104188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2000
Provider Second Line Business Mailing Address:
PMB 137
Provider Business Mailing Address City Name:
MERCEDITA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-290-3333
Provider Business Mailing Address Fax Number:
787-290-4444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TORRE MED SAN LUCAS
Provider Second Line Business Practice Location Address:
AVE. TITO CASTRO
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00716-4728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-290-3333
Provider Business Practice Location Address Fax Number:
787-290-4444
Provider Enumeration Date:
08/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DOMENECH FAGUNDO
Authorized Official First Name:
EDGAR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
787-290-3333

Provider Taxonomy Codes

  • Taxonomy code: 207YX0007X , with the licence number:  13247 , 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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