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General NPI Number Information
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NPI Number | 1083964357
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Entity Type | Organization
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Legal Business Name | RENALIFE, PSC
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Dates
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Enumeration Date | 09/14/2012
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Last Update Date | 06/25/2020
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Provider Practice Location Address
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Address Line | HOSPITAL AUXILIO MUTUO AVE PONCE DE LEON PDA 37 1/2
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City | SAN JUAN
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State | PR
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Zip | 00919
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Country | US
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Telephone | 787-458-2000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1947
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City | CAGUAS
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State | PR
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Zip | 00726-1947
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Country | US
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Telephone | 787-224-0499
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Fax | 787-687-7639
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GLENDA MICHELLE MIRANDA TIRADO
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Credential |
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Telephone | 787-224-0499
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 17265
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License Number State | PR
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