Healthcare Provider Details

I. General information

NPI: 1619958634
Provider Name (Legal Business Name): CENTRO OTOLOGICO DE PUERTO RICO CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CALLE DE DIEGO E SUITE 105
MAYAGUEZ PR
00680-5078
US

IV. Provider business mailing address

PO BOX 6428
MAYAGUEZ PR
00681-6428
US

V. Phone/Fax

Practice location:
  • Phone: 787-833-2155
  • Fax: 787-833-2680
Mailing address:
  • Phone: 787-833-2155
  • Fax: 787-833-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number11064
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number11064
License Number StatePR

VIII. Authorized Official

Name: MIGUEL A LASALLE LOPEZ
Title or Position: OWNER
Credential: MD
Phone: 787-833-2155