Healthcare Provider Details

I. General information

NPI: 1669204350
Provider Name (Legal Business Name): NLS GYN ONCOLOGY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 AVE PONCE DE LEON STE 814
SAN JUAN PR
00917-5031
US

IV. Provider business mailing address

100 CARR 165 STE 501
GUAYNABO PR
00968-8052
US

V. Phone/Fax

Practice location:
  • Phone: 787-945-2919
  • Fax:
Mailing address:
  • Phone: 305-613-3886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE LUGO SANTIAGO
Title or Position: PRESIDENT
Credential: MD
Phone: 305-613-3886