=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730531534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L. A PRIMARY CARE & SPECIALTY GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2016
-----------------------------------------------------
Last Update Date | 07/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CALLE DEL MUELLE CAPITOLIO PLAZA TORRE 1 1503
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00901-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-226-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11395
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00922-1395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-226-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAMON LUIS LOPEZ ACOSTA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-226-6359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 09645
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------