Healthcare Provider Details

I. General information

NPI: 1689018723
Provider Name (Legal Business Name): BREAST CANCER CARE, CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TORRE MED SAN LUCAS , SUITES 508-509
PONCE PR
00716-4728
US

IV. Provider business mailing address

609 AVE TITO CASTRO SUITE 102 PMB 464
PONCE PR
00716-0200
US

V. Phone/Fax

Practice location:
  • Phone: 787-651-6010
  • Fax: 787-651-6309
Mailing address:
  • Phone: 787-651-6010
  • Fax: 787-651-6309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number14399
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JORGE I RODRIGUEZ LUGO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-651-6010