Healthcare Provider Details

I. General information

NPI: 1295039626
Provider Name (Legal Business Name): AESTHETIC CENTER OF PUERTO RCO CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 AVE FONT MARTELO HOSPITAL RYDER OFICINA 402
HUMACAO PR
00791-3249
US

IV. Provider business mailing address

100 GRAND BLVD PASEO SUITE 112 MSC 486
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-850-8217
  • Fax:
Mailing address:
  • Phone: 787-850-8217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS IVAN MORELL
Title or Position: PRECIDENT
Credential:
Phone: 787-850-8217