MEDICARE: CENTRO RADIOLOGICO ROLON INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center
2	261QR0206X	Mammography Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0084911	OTHER	PR	MEDICARE ID

General Provider Information

NPI Number	:	1558352005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO RADIOLOGICO ROLON INC

Provider Business Mailing Address
First Line	:	PO BOX 142292
Second Line	:
City	:	ARECIBO
State	:	PR
Zip	:	00614-2292
Country	:	US
Telephone Number	:	787-879-0750
Fax Number	:	787-879-0772

Provider Business Practice Location Address
First Line	:	HC 5 BOX 93652
Second Line	:	BARRIO HATO ARRIBA
City	:	ARECIBO
State	:	PR
Zip	:	00612-9610
Country	:	US
Telephone Number	:	787-879-0750
Fax Number	:	787-879-0772

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CESAR A DEL VALLE BUGUE
Credential	:
Telephone Number	:	787-879-0750

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	07/30/2015

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