Healthcare Provider Details

I. General information

NPI: 1295020790
Provider Name (Legal Business Name): SOUTH RENAL CARE, P.S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 PONCE BY PASS CARIBBEAN MEDICAL CENTRE SUITE 202
PONCE PR
00717-1380
US

IV. Provider business mailing address

PO BOX 335251
PONCE PR
00733-5251
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-1445
  • Fax: 787-848-4657
Mailing address:
  • Phone: 787-840-1455
  • Fax: 787-848-4657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number016621
License Number StatePR

VIII. Authorized Official

Name: DR. LUIS A ORTIZ HEREDIA
Title or Position: PRESIDENT
Credential: MD
Phone: 787-362-0722