Provider Demographics
NPI:1134284425
Name:LARES MEDICAL GROUP
Entity Type:Organization
Organization Name:LARES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RODRIGUEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:BALTAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-897-1444
Mailing Address - Street 1:PO BOX 1427
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-1427
Mailing Address - Country:US
Mailing Address - Phone:787-897-1444
Mailing Address - Fax:787-897-4952
Practice Address - Street 1:CARR 111 KM 2.9
Practice Address - Street 2:AVE. LOS PATRIOTAS
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669-1427
Practice Address - Country:US
Practice Address - Phone:787-897-1444
Practice Address - Fax:787-897-4952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR22272Medicare UPIN