Provider Demographics
NPI:1295039626
Name:AESTHETIC CENTER OF PUERTO RCO CSP
Entity Type:Organization
Organization Name:AESTHETIC CENTER OF PUERTO RCO CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRECIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:MORELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-850-8217
Mailing Address - Street 1:100 GRAND BLVD PASEO
Mailing Address - Street 2:SUITE 112 MSC 486
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-850-8217
Mailing Address - Fax:
Practice Address - Street 1:355 AVE FONT MARTELO
Practice Address - Street 2:HOSPITAL RYDER OFICINA 402
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3249
Practice Address - Country:US
Practice Address - Phone:787-850-8217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20484MOMedicaid