Basic Information
| Provider Information | |||||||||
| NPI: | 1134245947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT LUKES MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SERVICIOS DE SALUD EPISCOPALES, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 336810 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007336810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | AVE. TITO CASTRO # 917 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007336810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878431600 | ||||||||
| FaxNumber: | 7876510572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VALENTIN | ||||||||
| AuthorizedOfficialFirstName: | CARLOS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7878442080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT LUKES MEMORIAL HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 07F1901 | PR | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4023519 | 01 | PR | NABP | OTHER |