Provider Demographics
NPI:1386815264
Name:JC ISLAND LITHOTRIPSY INC
Entity Type:Organization
Organization Name:JC ISLAND LITHOTRIPSY INC
Other - Org Name:ISLAND LITHOTRIPSY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA-ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-844-2080
Mailing Address - Street 1:609 AVE TITO CASTRO STE 102
Mailing Address - Street 2:PMB 382
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-0200
Mailing Address - Country:US
Mailing Address - Phone:787-844-2080
Mailing Address - Fax:787-840-5390
Practice Address - Street 1:909 AVE TITO CASTRO SAINT LUKES MEMORIAL HOSPITAL INC
Practice Address - Street 2:SECOND FLOOR IN FRONT OF OR
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4717
Practice Address - Country:US
Practice Address - Phone:787-844-2080
Practice Address - Fax:787-840-5390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038410300Medicaid