MEDICARE: GRUPO FISIATRICO CAROLINA LLC

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	208100000X	Physical Medicine & Rehabilitation Physician	14221	PR

General Provider Information

NPI Number	:	1619358033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRUPO FISIATRICO CAROLINA LLC

Provider Business Mailing Address
First Line	:	5-3 CALLE 8
Second Line	:	URB SABANA GARDENS
City	:	CAROLINA
State	:	PR
Zip	:	00983
Country	:	US
Telephone Number	:	787-400-0102
Fax Number	:	939-336-2485

Provider Business Practice Location Address
First Line	:	124 CALLE PLAZA SERENA
Second Line	:	URB ENTRERIOS
City	:	TRUJILLO ALTO
State	:	PR
Zip	:	00976-0000
Country	:	US
Telephone Number	:	787-400-0102
Fax Number	:	939-336-2485

Authorized Official
Title or Position	:	PRESIDENTA
Name	:	MAITE URQUIA ARAN
Credential	:	MD
Telephone Number	:	787-400-0102

Provider Enumeration Date	:	06/11/2015
Last Update Date	:	06/11/2015

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