Provider Demographics
NPI:1437571270
Name:SAN JORGE CHIROPRACTIC PSC
Entity Type:Organization
Organization Name:SAN JORGE CHIROPRACTIC PSC
Other - Org Name:SAN JORGE CHIROPRACTIC PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSUE
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:787-671-9555
Mailing Address - Street 1:403 CALLE SAN JORGE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00912-3313
Mailing Address - Country:US
Mailing Address - Phone:787-946-0011
Mailing Address - Fax:
Practice Address - Street 1:403 CALLE SAN JORGE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00912-3313
Practice Address - Country:US
Practice Address - Phone:787-946-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0059677Medicare PIN