Basic Information
| Provider Information | |||||||||
| NPI: | 1659680486 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SALA EMERGENCIAS SAN LUCAS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 336810 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007336810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | 7878447506 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR PR 2 KM 121.9 | ||||||||
| Address2: | COMUNIDAD BRISAS DEL CARIBE | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872591101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | GUILLERMO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7878442080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT LUKES MEMORIAL HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 31 | PR | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 10020 | 01 | PR | SSS | OTHER |