=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811216799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDI-K CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2010
-----------------------------------------------------
Last Update Date | 05/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE 4 C 8 URBANIZACION BRAZILIA
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-237-5901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3085
-----------------------------------------------------
City | VEGA ALTA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00692-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-237-5901
-----------------------------------------------------
Fax | 787-807-1288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTA
-----------------------------------------------------
Name | DR. IDA REGINA CORDERO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-237-5901
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 16991
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------