Basic Information
| Provider Information | |||||||||
| NPI: | 1023169034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTAMENTO DE SALUD OFICIAL | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEDIATRIC RENAL CENTER, UNIVERSITY PEDIATRIC HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191079 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874740333 | ||||||||
| FaxNumber: | 7877568907 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIVERSITY PEDIATRIC HOSPITAL | ||||||||
| Address2: | CARR 22 BO MONACILLO | ||||||||
| City: | RIO PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773232 | ||||||||
| FaxNumber: | 7877568907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIAZ GUZMAN | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7874740333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 34CNC NUM92-168 | PR | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.