Provider Demographics
NPI:1043679236
Name:RENOVA CORP. CSP
Entity Type:Organization
Organization Name:RENOVA CORP. CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-412-7009
Mailing Address - Street 1:CARR 2 KM 141.1 AVE SEVEREANO CUEVAS #18
Mailing Address - Street 2:WESTERN MEDICAL PLAZA 1ST FLOOR SUITE 24 AGUADILLA
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605
Mailing Address - Country:US
Mailing Address - Phone:787-412-7009
Mailing Address - Fax:787-919-0644
Practice Address - Street 1:CARR 2 KM 141.1 AVE SEVEREANO CUEVAS #18
Practice Address - Street 2:WESTERN MEDICAL PLAZA 1ST FLOOR SUITE # 24
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00605
Practice Address - Country:US
Practice Address - Phone:787-412-7009
Practice Address - Fax:787-919-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17029261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty