Healthcare Provider Details

I. General information

NPI: 1710186341
Provider Name (Legal Business Name): ASHFORD SPORTS & WELLNESS MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 ASHFORD
SAN JUAN PR
00907-1511
US

IV. Provider business mailing address

1451 ASHFORD
SAN JUAN PR
00907-1511
US

V. Phone/Fax

Practice location:
  • Phone: 787-724-3500
  • Fax: 787-725-0485
Mailing address:
  • Phone: 787-724-3500
  • Fax: 787-725-0485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number11046
License Number StatePR

VIII. Authorized Official

Name: DR. CARLOS E JIMENEZ
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 787-724-3500