Healthcare Provider Details

I. General information

NPI: 1851882898
Provider Name (Legal Business Name): LATITUD 18 NORTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 796 KM 0.3 BO RIO CANAS SECTOR LA GUASABARA
CAGUAS PR
00725
US

IV. Provider business mailing address

GRAN VISTA I 51 CALLE LA CEIBA
GURABO PR
00778
US

V. Phone/Fax

Practice location:
  • Phone: 939-204-9030
  • Fax: 939-204-9029
Mailing address:
  • Phone: 787-600-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20-F3553
License Number StatePR

VIII. Authorized Official

Name: MR. BENIGNO DOMINGUEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-600-0283