=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649480153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAJAOS MEDICAL CENTER CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 167 ROAD KM 11
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00956-9711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-730-3446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RR 5 BOX 5334
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00956-9711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-730-3446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAFAEL VAZQUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-730-3446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 9999
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------