Basic Information
Provider Information | |||||||||
NPI: | 1730309659 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORTIZ | ||||||||
FirstName: | ILEANA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | HC 83 BOX 7282 | ||||||||
Address2: |   | ||||||||
City: | VEGA ALTA | ||||||||
State: | PR | ||||||||
PostalCode: | 006929213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | CARR. #2 KM 39.5 BO. ALGARROBO | ||||||||
Address2: |   | ||||||||
City: | VEGA BAJA | ||||||||
State: | PR | ||||||||
PostalCode: | 00693 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7878581580 | ||||||||
FaxNumber: | 7878582385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | 2828 | PR | Y |   | Pharmacy Service Providers | Pharmacy Technician |   |
No ID Information.