=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750434346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICINA AUDAZ, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. KENNEDY # 18 CARR. # 2 KM 141.10 HOSPITAL BUEN SAMARITANO (1ST FLOOR)
-----------------------------------------------------
City | AGUADILLA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00603-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-819-1215
-----------------------------------------------------
Fax | 787-819-1215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1868 VICTORIA STATION
-----------------------------------------------------
City | AGUADILLA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00605-1868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-819-1215
-----------------------------------------------------
Fax | 787-819-1215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LUIS ACEVEDO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-819-1215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 125152
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------