=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689933632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS G SANTIAGO BALBES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2012
-----------------------------------------------------
Last Update Date | 12/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | URB HACIENDA CONCORDIA 11077
-----------------------------------------------------
City | SANTA ISABEL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00757-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-427-8374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | URB HACIENDA CONCORDIA 11077
-----------------------------------------------------
City | SANTA ISABEL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00757-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-427-8374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | TCAMB 691
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------