=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861530966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY RADIOLOGY SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 07/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 AVE DOMENECH
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-751-5685
-----------------------------------------------------
Fax | 787-751-8432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | DOMENECH 303
-----------------------------------------------------
City | HATO REY
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-751-5685
-----------------------------------------------------
Fax | 787-751-8432
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | YOLANDA COSTA SOTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-751-5685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 5242
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------