=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457650855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1 CARDIOVASCULAR DIAGNOSTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE SABOYA A4 VILLA DEL REY 3RA
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725
-----------------------------------------------------
Country | UM
-----------------------------------------------------
Telephone | 787-375-5119
-----------------------------------------------------
Fax | 787-258-5487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4960 PMB 254
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00726-4960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-375-5119
-----------------------------------------------------
Fax | 787-258-5487
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. FERNANDO JIMENEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-375-5119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------