Provider Demographics
NPI:1083964357
Name:RENALIFE, PSC
Entity Type:Organization
Organization Name:RENALIFE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MIRANDA TIRADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-224-0499
Mailing Address - Street 1:PO BOX 1947
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-1947
Mailing Address - Country:US
Mailing Address - Phone:787-224-0499
Mailing Address - Fax:787-687-7639
Practice Address - Street 1:HOSPITAL AUXILIO MUTUO
Practice Address - Street 2:AVE PONCE DE LEON PDA 37 1/2
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00919
Practice Address - Country:US
Practice Address - Phone:787-458-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17265207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty