Healthcare Provider Details

I. General information

NPI: 1053962514
Provider Name (Legal Business Name): PEDIATRIC ORTHOPEDICS OF PUERTO RICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 AVENIDA HOSTOS CARR #2 KM 157 SUITE 117
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 3073
MAYAGUEZ PR
00681-3073
US

V. Phone/Fax

Practice location:
  • Phone: 787-478-0782
  • Fax:
Mailing address:
  • Phone: 787-478-0782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ERNESTO JOSE DEL VALLE HERNANDEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-478-0782