Basic Information
| Provider Information | |||||||||
| NPI: | 1083964357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENALIFE, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1947 | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007261947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872240499 | ||||||||
| FaxNumber: | 7876877639 | ||||||||
| Practice Location | |||||||||
| Address1: | HOSPITAL AUXILIO MUTUO | ||||||||
| Address2: | AVE PONCE DE LEON PDA 37 1/2 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874582000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2012 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | MIRANDA TIRADO | ||||||||
| AuthorizedOfficialFirstName: | GLENDA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7872240499 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 17265 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.