Provider Demographics
NPI:1053649228
Name:KARDIONUCLEAR, INC.
Entity Type:Organization
Organization Name:KARDIONUCLEAR, INC.
Other - Org Name:KARDIONUCLEAR
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CONFESOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LASALLE-RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-551-0215
Mailing Address - Street 1:PO BOX 976
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-0976
Mailing Address - Country:US
Mailing Address - Phone:787-551-0215
Mailing Address - Fax:787-551-0214
Practice Address - Street 1:550 CALLE CONCEPCION VERA AYALA
Practice Address - Street 2:HOSPITAL SAN CARLOS BORROMEO 1ER PISO
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-0000
Practice Address - Country:US
Practice Address - Phone:787-551-0215
Practice Address - Fax:787-551-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7172207RC0000X
PR11046207U00000X
PR261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR52-35164-01OtherNRC
PR51220-02OtherACR