Provider Demographics
NPI:1154056950
Name:ORTIZ, JUAN CARLOS
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVE. LAUREL #100 SANTA JUANITA
Mailing Address - Street 2:2DO PISO HURRA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00965
Mailing Address - Country:US
Mailing Address - Phone:787-338-8383
Mailing Address - Fax:
Practice Address - Street 1:100 AVE LAUREL
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-4816
Practice Address - Country:US
Practice Address - Phone:787-338-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder