=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730275900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUPO CLINICO DEL NORTE CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE TULIO OTERO #8
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-807-2974
-----------------------------------------------------
Fax | 787-807-2974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BOX 3244
-----------------------------------------------------
City | MANATI
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-807-2974
-----------------------------------------------------
Fax | 787-807-2974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT SUPERVISOR
-----------------------------------------------------
Name | MILAGROS GONZALEZ
-----------------------------------------------------
Credential | BSMT ASCP
-----------------------------------------------------
Telephone | 787-807-2974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1072
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------