Healthcare Provider Details

I. General information

NPI: 1750434346
Provider Name (Legal Business Name): MEDICINA AUDAZ, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. KENNEDY # 18 CARR. # 2 KM 141.10 HOSPITAL BUEN SAMARITANO (1ST FLOOR)
AGUADILLA PR
00603-0000
US

IV. Provider business mailing address

PO BOX 1868 VICTORIA STATION
AGUADILLA PR
00605-1868
US

V. Phone/Fax

Practice location:
  • Phone: 787-819-1215
  • Fax: 787-819-1215
Mailing address:
  • Phone: 787-819-1215
  • Fax: 787-819-1215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number125152
License Number StatePR

VIII. Authorized Official

Name: DR. LUIS ACEVEDO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-819-1215