Basic Information
| Provider Information | |||||||||
| NPI: | 1063038602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTELA DE LA LUZ | ||||||||
| FirstName: | MELISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 288 CALLE ALFREDO GALVEZ | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009265838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876004586 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4 CALLE HERADIO MENDOZA ESTE | ||||||||
| Address2: | |||||||||
| City: | CAYEY | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875351001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2020 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | PR | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.