Healthcare Provider Details

I. General information

NPI: 1679040968
Provider Name (Legal Business Name): CRIOLITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 COND PUERTA DEL PARQUE
CAGUAS PR
00727-3142
US

IV. Provider business mailing address

1408 COND PUERTA DEL PARQUE
CAGUAS PR
00727-3142
US

V. Phone/Fax

Practice location:
  • Phone: 787-426-5649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name: ROSA GARCIA
Title or Position: OWNER
Credential:
Phone: 787-426-5649