Healthcare Provider Details

I. General information

NPI: 1053052852
Provider Name (Legal Business Name): DE DIEGO AMBULATORY CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 AVE DE DIEGO STE 1
SAN JUAN PR
00907-2309
US

IV. Provider business mailing address

150 AVE DE DIEGO STE 1
SAN JUAN PR
00907-2309
US

V. Phone/Fax

Practice location:
  • Phone: 787-977-7575
  • Fax: 787-977-7586
Mailing address:
  • Phone: 787-977-7575
  • Fax: 787-977-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM JIMENEZ
Title or Position: BILLING AND COLLECTION MANAGER
Credential:
Phone: 787-977-7575