=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053977322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COROZAL HEALTH PROFESSIONAL SERVICES, CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2019
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 159 # KM15.5
-----------------------------------------------------
City | COROZAL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00783-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-600-4288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 1 BOX 3143
-----------------------------------------------------
City | COROZAL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00783-9407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-600-4288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTA
-----------------------------------------------------
Name | JULIA M PEREZ MARZAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-600-4288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------