=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326791849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHO ELITE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2022
-----------------------------------------------------
Last Update Date | 02/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 CARR 869
-----------------------------------------------------
City | CATANO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00962-7075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-664-8721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | VILLA BORINQUEN 31 C/LOPEZ LANDRON
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FERNANDO LOPEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-664-8721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------