=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629439641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC CARE PR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2016
-----------------------------------------------------
Last Update Date | 03/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 CALLE GEORGETTI
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00925-3607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-450-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 41234
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00940-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-450-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTA
-----------------------------------------------------
Name | DR. OLGA M LLITERAS
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 787-375-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 13897
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------