Healthcare Provider Details

I. General information

NPI: 1710370630
Provider Name (Legal Business Name): SPORTS MEDICINE CAGUAS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 GAUTIER BENITEZ AVE CONSOLIDATED MEDICAL PLAZA STE 305
CAGUAS PR
00725
US

IV. Provider business mailing address

35 JUAN C. BORBON STE 67 PMB 327
GUAYNABO PR
00969
US

V. Phone/Fax

Practice location:
  • Phone: 787-704-0033
  • Fax: 787-704-0090
Mailing address:
  • Phone: 787-704-0033
  • Fax: 787-704-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: LUIS ALEXANDER MIRANDA
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 787-306-0118