Healthcare Provider Details

I. General information

NPI: 1750609319
Provider Name (Legal Business Name): ANGELORUM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 693 KM 13.8 SUITE 171 BO BRENAS
VEGA ALTA PR
00692
US

IV. Provider business mailing address

PO BOX 356
VEGA ALTA PR
00692-0356
US

V. Phone/Fax

Practice location:
  • Phone: 787-270-4747
  • Fax: 787-270-4747
Mailing address:
  • Phone: 787-270-4747
  • Fax: 787-270-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number57474
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number57474
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number57474
License Number StatePR

VIII. Authorized Official

Name: DR. LUIS M GONZALEZ BERMUDEZMD
Title or Position: PRESIDENT
Credential: MD
Phone: 787-270-4747