Provider Demographics
NPI:1437332624
Name:PRESTIGE MEDICAL GROUP LJCPSC
Entity Type:Organization
Organization Name:PRESTIGE MEDICAL GROUP LJCPSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOSQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-760-6604
Mailing Address - Street 1:MONTEHIEDRA
Mailing Address - Street 2:GUARAGUAO 145
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-760-6604
Mailing Address - Fax:787-292-0130
Practice Address - Street 1:MONTEHEIDRA TOWN CTR
Practice Address - Street 2:GUARAGUAO 145
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-7007
Practice Address - Country:US
Practice Address - Phone:787-760-6604
Practice Address - Fax:787-292-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4863207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4863OtherLIC