Healthcare Provider Details

I. General information

NPI: 1306207972
Provider Name (Legal Business Name): WELL&LEAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 AVE HOSTOS URB VEDADO
SAN JUAN PR
00918-3014
US

IV. Provider business mailing address

PO BOX 191147
SAN JUAN PR
00919-1147
US

V. Phone/Fax

Practice location:
  • Phone: 787-946-4501
  • Fax:
Mailing address:
  • Phone: 787-946-4501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number2745
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number2745
License Number StatePR

VIII. Authorized Official

Name: LESLIE E DOMINGUEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-596-0358