=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225527542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUCLEAR SCAN PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2018
-----------------------------------------------------
Last Update Date | 05/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 CALLE CARAZO
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00969-5636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-642-7489
-----------------------------------------------------
Fax | 787-642-7489
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 367580
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00936-7580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUAN FONTANEZ NIEVES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-642-7489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207UN0901X
-----------------------------------------------------
Taxonomy Name | Nuclear Cardiology Physician
-----------------------------------------------------
License Number | 13021
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------