Provider Demographics
NPI:1386199032
Name:NCDERM LLC
Entity Type:Organization
Organization Name:NCDERM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:SOFIA
Authorized Official - Last Name:CARVAJAL DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-360-6112
Mailing Address - Street 1:1353 AVE LUIS VIGOREAUX
Mailing Address - Street 2:PMB 322
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2715
Mailing Address - Country:US
Mailing Address - Phone:787-626-3431
Mailing Address - Fax:787-626-5163
Practice Address - Street 1:500 DEGETAU AVENUE
Practice Address - Street 2:HIMA PLAZA I, SUITE 513
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-626-3431
Practice Address - Fax:787-626-5163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19082261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty