Provider Demographics
NPI:1316384100
Name:GASTROINTESTINAL DIAGNOSTIC CLINIC OF PR, LLC
Entity Type:Organization
Organization Name:GASTROINTESTINAL DIAGNOSTIC CLINIC OF PR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-646-9724
Mailing Address - Street 1:1353 AVE LUIS VIGOREAUX
Mailing Address - Street 2:PMB 389
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2715
Mailing Address - Country:US
Mailing Address - Phone:787-884-0310
Mailing Address - Fax:787-854-3270
Practice Address - Street 1:CALLE SGTO. HERNANDEZ CARRION
Practice Address - Street 2:MMC PROFESSIONAL PLAZA, SUITE 307
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-884-0310
Practice Address - Fax:787-854-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18138261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy