Healthcare Provider Details

I. General information

NPI: 1992998785
Provider Name (Legal Business Name): INNOVATIVE MEDICAL AND RADIOLOGY MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 165 KM 8.1
TOA ALTA PR
00953
US

IV. Provider business mailing address

162 CALLE BEGONIA CIUDAD JARDIN 2
TOA ALTA PR
00953-4855
US

V. Phone/Fax

Practice location:
  • Phone: 787-730-1166
  • Fax:
Mailing address:
  • Phone: 787-730-1166
  • Fax: 787-746-1425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN CARLOS DEL RIO ROURE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-730-1166