Healthcare Provider Details

I. General information

NPI: 1629832266
Provider Name (Legal Business Name): ELEINE M SAMBOLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STREET 3 URBANIZACION EL CONVENTO
SAN GERMAN PR
00683
US

IV. Provider business mailing address

STREET 3 URBANIZACIO EL CONVENTO A 51
SAN GERMAN PR
00683
US

V. Phone/Fax

Practice location:
  • Phone: 407-968-4748
  • Fax:
Mailing address:
  • Phone: 939-265-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number24809
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: