Provider Demographics
NPI:1417942640
Name:REHABIBILITACION PONCE DE LEON CLINICA DE TERAPIA FISICA
Entity Type:Organization
Organization Name:REHABIBILITACION PONCE DE LEON CLINICA DE TERAPIA FISICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRDOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:787-856-5272
Mailing Address - Street 1:42 CALLE MATTEI LLUBERAS
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-3630
Mailing Address - Country:US
Mailing Address - Phone:787-856-5272
Mailing Address - Fax:787-856-8421
Practice Address - Street 1:42 CALLE MATTEI LLUBERAS
Practice Address - Street 2:SUITE 1
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698-3630
Practice Address - Country:US
Practice Address - Phone:787-856-5272
Practice Address - Fax:787-856-8421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084104OtherTRIPLE S
PR84104Medicare ID - Type Unspecified