=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407181159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENUELAS X RAY CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2009
-----------------------------------------------------
Last Update Date | 03/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | STREET MUNOZ RIVERA # 907
-----------------------------------------------------
City | PENUELAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00624-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-486-1512
-----------------------------------------------------
Fax | 787-841-1725
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | STREET MUNOZ RIVERA # 907
-----------------------------------------------------
City | PENUELAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00624-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-486-1512
-----------------------------------------------------
Fax | 787-841-1725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RAFAEL A MORA
-----------------------------------------------------
Credential | RT
-----------------------------------------------------
Telephone | 787-486-1512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------