Healthcare Provider Details

I. General information

NPI: 1902804545
Provider Name (Legal Business Name): SAN SEBASTIAN X RAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 111 KM 18.0 BIO MAHOMAMEY
SAN SEBASTIAN PR
00685
US

IV. Provider business mailing address

PO BOX 3144
SAN SEBASTIAN PR
00685-7003
US

V. Phone/Fax

Practice location:
  • Phone: 787-280-0981
  • Fax: 787-280-0984
Mailing address:
  • Phone: 787-280-0981
  • Fax: 787-280-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number232321
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAISA MUSA QUINONES
Title or Position: OWNER
Credential:
Phone: 787-280-0981