Basic Information
Provider Information | |||||||||
NPI: | 1518453299 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YLC MIGS-CPP SPECIALIST LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 CALLE LUNA | ||||||||
Address2: | URB ADOQUINES | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 00926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7872935386 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 735 AVE PONCE DE LEON STE 812 | ||||||||
Address2: |   | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009175031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877582000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2018 | ||||||||
LastUpdateDate: | 07/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOZADA | ||||||||
AuthorizedOfficialFirstName: | YOLIANNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7873071100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X |   | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
ID | Type | State | Issuer | Description | 1144584012 | 01 |   | NPI | OTHER |