1952395857 NPI number — MRS. XENIA MEDINA-ROQUE DC

Table of content: MRS. XENIA MEDINA-ROQUE DC (NPI 1952395857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952395857 NPI number — MRS. XENIA MEDINA-ROQUE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA-ROQUE
Provider First Name:
XENIA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

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:
1952395857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 MENDEZ VIGO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-848-6539
Provider Business Mailing Address Fax Number:
787-848-6539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37 MENDEZ VIGO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-848-6539
Provider Business Practice Location Address Fax Number:
787-848-6539
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  295 , 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: 7310384 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5473 . This is a "IMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 601609 . This is a "MMM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 233007 . This is a "PREFERRED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35105 . This is a "SSS" identifier . This identifiers is of the category "OTHER".




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