1972016335 NPI number — MISS ELIANNE MARIE MEDINA LOPEZ

Table of content: MISS ELIANNE MARIE MEDINA LOPEZ (NPI 1972016335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972016335 NPI number — MISS ELIANNE MARIE MEDINA LOPEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA LOPEZ
Provider First Name:
ELIANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDINA
Provider Other First Name:
ELIANNE
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1972016335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 607087
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYAMON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00960-7087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 CALLE ISABEL
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:
00730-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-848-3073
Provider Business Practice Location Address Fax Number:
787-812-0301
Provider Enumeration Date:
11/08/2017

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: 104100000X , with the licence number:  14004 , 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: $$$$$$$$$ , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com