Healthcare Provider Details

I. General information

NPI: 1093130833
Provider Name (Legal Business Name): TIENDA DE ZAPATOS PIE DIVINO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MUNOZ RIVERA 59
FAJARDO PR
00738
US

IV. Provider business mailing address

MUNOZ RIVERA 59
FAJARDO PR
00738
US

V. Phone/Fax

Practice location:
  • Phone: 787-801-0765
  • Fax:
Mailing address:
  • Phone: 787-801-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: NELSON CASTILLO
Title or Position: OWNER
Credential: OWNER
Phone: 787-801-0765