Healthcare Provider Details

I. General information

NPI: 1801115605
Provider Name (Legal Business Name): AMANECER MUTUO, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5725 BLVD. MEDIA LUNA, SUITE # 5 GALERIAS DE ESCORIAL SHOPPING CENTER
CAROLINA PR
00987
US

IV. Provider business mailing address

PO BOX 1893
CAROLINA PR
00984-1893
US

V. Phone/Fax

Practice location:
  • Phone: 787-453-0563
  • Fax:
Mailing address:
  • Phone: 787-453-0563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number16005
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2751
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE A LOPEZ-CALERO
Title or Position: PRESIDENT
Credential: DMD
Phone: 787-453-0563