Healthcare Provider Details

I. General information

NPI: 1487946174
Provider Name (Legal Business Name): INOVATIVE MEDICALGROUPINC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOULERVARD DEL RIO #2
SAN JUAN PR
00928-5129
US

IV. Provider business mailing address

PO BOX 25129
SAN JUAN PR
00928-5129
US

V. Phone/Fax

Practice location:
  • Phone: 787-429-4407
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2846
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE M LOPEZ
Title or Position: PRESIDENTE
Credential: MD
Phone: 787-429-4407