Healthcare Provider Details

I. General information

NPI: 1841601978
Provider Name (Legal Business Name): REY LUGO SR. LICENCIIADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MISS VILMA LUGO

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7908 CALLE DR. JOSE HENNA URB. MARIANI
PONCE PUERTO RICO
00717
UM

IV. Provider business mailing address

7908 CALLE DR. JOSE HENNA URB. MARIAN
PONCE PR
00717-0217
US

V. Phone/Fax

Practice location:
  • Phone: 787-396-2905
  • Fax: 787-844-2624
Mailing address:
  • Phone: 787-396-2905
  • Fax: 787-844-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1046
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: