=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386445096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOGAVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2025
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 165 KM 0 SUITE 1010 CITY VIEW PLAZA II
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00968-0096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-460-8328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 COBANA ST URB LADERAS DE SAN JUAN
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-460-8328
-----------------------------------------------------
Fax | 787-474-8328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL OTERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-460-8328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------