Healthcare Provider Details

I. General information

NPI: 1043679236
Provider Name (Legal Business Name): RENOVA CORP. CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 2 KM 141.1 AVE SEVEREANO CUEVAS #18 WESTERN MEDICAL PLAZA 1ST FLOOR SUITE # 24
AGUADILLA PR
00605
US

IV. Provider business mailing address

CARR 2 KM 141.1 AVE SEVEREANO CUEVAS #18 WESTERN MEDICAL PLAZA 1ST FLOOR SUITE 24 AGUADILLA
AGUADILLA PR
00605
US

V. Phone/Fax

Practice location:
  • Phone: 787-412-7009
  • Fax: 787-919-0644
Mailing address:
  • Phone: 787-412-7009
  • Fax: 787-919-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number17029
License Number StatePR

VIII. Authorized Official

Name: DR. JANICE MARIE RODRIGUEZ
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 787-412-7009