Healthcare Provider Details

I. General information

NPI: 1295223055
Provider Name (Legal Business Name): PEDIATRIC PRO & MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE JOSE C VAZQUEZ CARRETERA 726 URB VLLA ROSALES
AIBONITO PR
00705
US

IV. Provider business mailing address

PO BOX 8549
CAGUAS PR
00726-8549
US

V. Phone/Fax

Practice location:
  • Phone: 787-735-8100
  • Fax: 787-924-7575
Mailing address:
  • Phone: 787-924-7575
  • Fax: 787-924-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JORGE E DEL VALLE
Title or Position: ADMINISTRATOR
Credential: PE
Phone: 787-924-7575