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General NPI Number Information
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NPI Number | 1215387691
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Entity Type | Organization
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Legal Business Name | BEAU DERM LLC
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Dates
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Enumeration Date | 06/16/2016
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Last Update Date | 09/06/2016
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Provider Practice Location Address
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Address Line | 516B CALLE JUAN J JIMENEZ
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City | SAN JUAN
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State | PR
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Zip | 00918-2605
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Country | US
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Telephone | 787-751-6018
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Fax |
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Provider Business Mailing Address
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Address Line | 64 AVENIDA CONDADO PLAZA DEL CONDADO 1202
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City | SAN JUAN
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State | PR
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Zip | 00907-1894
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | AILEEN E SANTOS
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Credential | M.D.
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Telephone | 787-484-2533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 19043
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License Number State | PR
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