Basic Information
| Provider Information | |||||||||
| NPI: | 1386815264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JC ISLAND LITHOTRIPSY INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ISLAND LITHOTRIPSY INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 AVE TITO CASTRO STE 102 | ||||||||
| Address2: | PMB 382 | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007160200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | 7878405390 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 AVE TITO CASTRO SAINT LUKES MEMORIAL HOSPITAL INC | ||||||||
| Address2: | SECOND FLOOR IN FRONT OF OR | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007164717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | 7878405390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MENDOZA-ROSA | ||||||||
| AuthorizedOfficialFirstName: | FELIX | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7878442080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QL0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Lithotripsy | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 038410300 | 05 | PR | MEDICAID |