=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285879296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUPO PEDIATRICO CIUDAD UNIVERSITARIA, CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2008
-----------------------------------------------------
Last Update Date | 11/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | D14 AVE AA CIUDAD UNIVERSITARIA
-----------------------------------------------------
City | TRUJILLO ALTO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00976-3151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-755-4270
-----------------------------------------------------
Fax | 787-755-1122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1795 CALLE GARDENIA MANSIONES DE RIO PIEDRAS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-7212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-755-4270
-----------------------------------------------------
Fax | 787-755-1122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICARDO PACHECO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-755-4270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4934
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------