1821458704 NPI number — SICK BLOOD MED SERV CSP

Table of content: (NPI 1821458704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821458704 NPI number — SICK BLOOD MED SERV CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SICK BLOOD MED SERV CSP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821458704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
369 CALLE DE DIEGO STE 603-604
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00923-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-753-6022
Provider Business Mailing Address Fax Number:
787-753-6066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
369 CALLE DE DIEGO STE 603-604
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00923-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-753-6022
Provider Business Practice Location Address Fax Number:
787-753-6066
Provider Enumeration Date:
03/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SOLIVAN ORTIZ
Authorized Official First Name:
PEDRO
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-771-7933

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  17625 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 17625 . This is a "LIC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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