=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669010351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND NATURAL HEALTH FOOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2019
-----------------------------------------------------
Last Update Date | 12/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 CALLE ROSA URB. FERRY BARRANCA
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-813-1123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HACIENDA LAS VEGAS 117 CALLE GAVIOTA
-----------------------------------------------------
City | JUANA DIAZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00795-7003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-813-1123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAMON ANTONIO PAGAN DE JESUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-813-1123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335G00000X
-----------------------------------------------------
Taxonomy Name | Medical Foods Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------