Healthcare Provider Details

I. General information

NPI: 1326318387
Provider Name (Legal Business Name): EA SPORT MEDICAL EQUIPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST 194 KM 3.0 LOCAL 1
FAJARDO PR
00738
US

IV. Provider business mailing address

2F24 CALLE 6 VISTAS DEL CONVENTO
FAJARDO PR
00738-3207
US

V. Phone/Fax

Practice location:
  • Phone: 787-909-8975
  • Fax: 787-863-7199
Mailing address:
  • Phone: 787-909-8975
  • Fax: 787-863-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. ENRIQUE JOSE FIGUEROA
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-909-8975