=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497023592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGUNA GARDENS RADIOLOGY AND IMAGING GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2011
-----------------------------------------------------
Last Update Date | 04/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | LAGUNA GARDENS SHOPPING CENTER SUITE 106
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00979-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-253-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | LAGUNA GARDENS SHOPPING CENTER SUITE 106
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00979-6525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-253-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | LUZ M. VILLANUEVA DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-253-7070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------