MEDICARE: MEDICINA AUDAZ, 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	261Q00000X	Clinic/Center	125152	PR

General Provider Information

NPI Number	:	1750434346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICINA AUDAZ, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1868
Second Line	:	VICTORIA STATION
City	:	AGUADILLA
State	:	PR
Zip	:	00605-1868
Country	:	US
Telephone Number	:	787-819-1215
Fax Number	:	787-819-1215

Provider Business Practice Location Address
First Line	:	AVE. KENNEDY # 18 CARR. # 2 KM 141.10
Second Line	:	HOSPITAL BUEN SAMARITANO (1ST FLOOR)
City	:	AGUADILLA
State	:	PR
Zip	:	00603-0000
Country	:	US
Telephone Number	:	787-819-1215
Fax Number	:	787-819-1215

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LUIS ACEVEDO
Credential	:	M.D.
Telephone Number	:	787-819-1215

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	08/22/2020

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