Healthcare Provider Details

I. General information

NPI: 1497171359
Provider Name (Legal Business Name): MRS. SANDRA ELENA HURTADO PONCE DE LEON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND MIRAMAR # 902 PONCE DE LEON AVE. APT 306
SAN JUAN PR
00907-3458
US

IV. Provider business mailing address

MIRAMAR EMBASSY 902 PONCE DE LEON AVE. APT 306
SAN JUAN PR
00907
US

V. Phone/Fax

Practice location:
  • Phone: 787-533-3390
  • Fax:
Mailing address:
  • Phone: 787-533-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number2110780
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: