Healthcare Provider Details

I. General information

NPI: 1457328312
Provider Name (Legal Business Name): CLINICA OFTALMICA DE LA MONTANA, C.S.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 CALLE PEDRO ROSARIO
AIBONITO PR
00705-3238
US

IV. Provider business mailing address

56 CALLE PEDRO ROSARIO PO BOX 455
AIBONITO PR
00705-3238
US

V. Phone/Fax

Practice location:
  • Phone: 787-991-1325
  • Fax: 787-991-2305
Mailing address:
  • Phone: 787-991-1325
  • Fax: 787-991-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number12782
License Number StatePR

VIII. Authorized Official

Name: DR. LUIS RAUL SANTIAGO-PAGAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-991-1325