Basic Information
Provider Information | |||||||||
NPI: | 1366821290 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRO DE DIALISIS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 372800 | ||||||||
Address2: |   | ||||||||
City: | CAYEY | ||||||||
State: | PR | ||||||||
PostalCode: | 007372800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7875351001 | ||||||||
FaxNumber: | 7875351114 | ||||||||
Practice Location | |||||||||
Address1: | CARRETERA 172 CAGUAS A CIDRA | ||||||||
Address2: | SALIDA 21 | ||||||||
City: | CAGUAS | ||||||||
State: | PR | ||||||||
PostalCode: | 00725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7875351001 | ||||||||
FaxNumber: | 7875351114 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2015 | ||||||||
LastUpdateDate: | 05/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARCADO-SURO | ||||||||
AuthorizedOfficialFirstName: | MARTA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 7875351001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HOSPITAL MENONITA CAGUAS INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.