=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093347692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE MEDICAL CLINIC OF PR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2020
-----------------------------------------------------
Last Update Date | 02/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 AVE DOMENECH STE 412 LAS AMERICAS PROFESSIONAL CENTER
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-945-0767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 AVE DOMENECH STE 412 LAS AMERICAS PROFESSIONAL CENTER
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-945-0767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | YADIRA DOMINGUEZ VAZQUEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-239-7575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------