=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588959506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LVS FAMILY MEDICINE PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2011
-----------------------------------------------------
Last Update Date | 05/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8133 CALLE CONCORDIA SUITE 202
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-1700
-----------------------------------------------------
Fax | 787-842-0900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5038
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00733-5038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-1700
-----------------------------------------------------
Fax | 787-842-0900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | MRS. SHEILA M LOPERENA MONTALBAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-843-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 13345
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------