Provider Demographics
NPI:1558016634
Name:LIC EXPRESS-INTERNISTA INC
Entity Type:Organization
Organization Name:LIC EXPRESS-INTERNISTA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEZARES TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-347-7863
Mailing Address - Street 1:6 CALLE PROLONGACION C AGUILER
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-2830
Mailing Address - Country:US
Mailing Address - Phone:787-744-5042
Mailing Address - Fax:787-286-1313
Practice Address - Street 1:6 CALLE PROLONGACION C AGUILER
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-2830
Practice Address - Country:US
Practice Address - Phone:787-744-5042
Practice Address - Fax:787-286-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty