Healthcare Provider Details

I. General information

NPI: 1457506883
Provider Name (Legal Business Name): JOSE MIGUEL CANDELARIO SR. CO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CASIA STREET VA MEDICAL CENTER
SAN JUAN PR
00921
US

IV. Provider business mailing address

10 CASIA STREET VA MEDICAL CENTER
SAN JUAN PR
00921
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-7582
  • Fax: 787-662-4821
Mailing address:
  • Phone: 787-641-7582
  • Fax: 787-662-4821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number# 190
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: