=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760427744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPRAMED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | DE DIEGO AVENUE #359 ALTOS #319 ALTOS
-----------------------------------------------------
City | RIO PIEDRAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-759-6265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ROAD #19 GARDEN HILL PLAZA #1353 PMB #228
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-759-6265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. JORGE CARBALLIDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-759-6265
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | TCAMB-108
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------