MEDICARE: SOUTH PEARL MEDICAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1801379052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PEARL MEDICAL CORP

Provider Business Mailing Address
First Line	:	909 AVE TITO CASTRO STE 714
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00716-4722
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 CALLE MAYOR
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00730-3761
Country	:	US
Telephone Number	:	787-437-1601
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SARA MIRANDA
Credential	:
Telephone Number	:	787-903-4999

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	09/13/2018

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