Healthcare Provider Details

I. General information

NPI: 1588836290
Provider Name (Legal Business Name): CICER CSP CENTRO INTEGRAL DE CIRUGIA ESTETICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 AVE HOSTOS CENTRO MEDICO DE MAYAGUEZ
MAYAGUEZ PR
00682-1560
US

IV. Provider business mailing address

410 AVE HOSTOS CENTRO MEDICO DE MAYAGUEZ
MAYAGUEZ PR
00682-1560
US

V. Phone/Fax

Practice location:
  • Phone: 787-986-7085
  • Fax: 787-986-7086
Mailing address:
  • Phone: 787-986-7085
  • Fax: 787-986-7086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number13636
License Number StatePR

VIII. Authorized Official

Name: DR. GUSTAVO ENRIQUE BELLO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-986-7085