=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255878930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA CLINICA DE RINOSINUSITIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 917 AVE TITO CASTRO SUITE 618 TORRE MEDICA SAN LUCAS
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-432-7338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 MENDEZ VIGO W
-----------------------------------------------------
City | MAYAGUEZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00680-6662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LUIS A TARRATS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-432-7338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------