Healthcare Provider Details

I. General information

NPI: 1811238496
Provider Name (Legal Business Name): JESUS MANUEL BURGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 CARR S STE1
BARCELONETA PR
00617-3355
US

IV. Provider business mailing address

PO BOX 3162
MANATI PR
00674-3162
US

V. Phone/Fax

Practice location:
  • Phone: 787-846-4583
  • Fax: 787-846-2334
Mailing address:
  • Phone: 787-597-6472
  • Fax: 787-846-2334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number004895
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: