Healthcare Provider Details

I. General information

NPI: 1558265207
Provider Name (Legal Business Name): LA SOMBRA DEL OMNIPOTENTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE MUNOZ RIVERA #80 SUITE B
CAMUY PR
00627-2631
US

IV. Provider business mailing address

URB LAS VEREDAS 130 CALLE ALELI
CAMUY PR
00627-0130
US

V. Phone/Fax

Practice location:
  • Phone: 787-219-6405
  • Fax: 939-585-0156
Mailing address:
  • Phone: 787-214-2067
  • Fax: 939-585-0156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELIEL MIRANDA
Title or Position: PRESIDENT
Credential: MD
Phone: 787-214-2067