Healthcare Provider Details

I. General information

NPI: 1982184941
Provider Name (Legal Business Name): INNOVATIVE CARDIOLOGY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIMA PLAZA 1 OFIC 305 100 AVE LUIS MUNOZ MARIN
CAGUAS PR
00725
US

IV. Provider business mailing address

COND REGENCY PARK APT 305 3F 155 CALLE CARAZO
GUAYNABO PR
00971
US

V. Phone/Fax

Practice location:
  • Phone: 787-920-4090
  • Fax:
Mailing address:
  • Phone: 787-354-7853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18640
License Number StatePR

VIII. Authorized Official

Name: BLADIMIR SANCHEZ PEREZ
Title or Position: PRESIDENTE
Credential: MD
Phone: 787-354-7853