Healthcare Provider Details

I. General information

NPI: 1306071451
Provider Name (Legal Business Name): PREMIUM HEALTH GROUP CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LAGUNA GARDENS SHOPPING CENTER SUITE 101A
CAROLINA PR
00979
US

IV. Provider business mailing address

LAGUNA GARDENS SHOPPING CENTER SUITE 101-A
CAROLINA PR
00979
US

V. Phone/Fax

Practice location:
  • Phone: 787-253-1101
  • Fax: 787-791-6273
Mailing address:
  • Phone: 787-253-1101
  • Fax: 787-791-6273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEX CARRASQUILLO
Title or Position: ADMINISTRATOR
Credential: DMD
Phone: 787-253-1101