Healthcare Provider Details

I. General information

NPI: 1134581507
Provider Name (Legal Business Name): IDN. SVC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 2 KM 47.7
MANATI PR
00674
US

IV. Provider business mailing address

PO BOX 2362
MANATI PR
00674
US

V. Phone/Fax

Practice location:
  • Phone: 787-375-7474
  • Fax:
Mailing address:
  • Phone: 787-375-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number12447
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier12447
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerMEDICAL LICENCE

VIII. Authorized Official

Name: DR. WANDA I TORRES-LOPEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-375-7474