Provider Demographics
NPI:1568679777
Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO INC
Entity Type:Organization
Organization Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO INC
Other - Org Name:RENAL CENTER OF LARES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-292-7979
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:SAINT JUST STATION
Mailing Address - City:SAINT JUST
Mailing Address - State:PR
Mailing Address - Zip Code:00978-1350
Mailing Address - Country:US
Mailing Address - Phone:787-292-7979
Mailing Address - Fax:787-292-7999
Practice Address - Street 1:CARRETERA 129 KM 25.6
Practice Address - Street 2:BO. PILETAS CASTRO BOROUGH
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-292-7979
Practice Address - Fax:787-292-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLIC # 18 CNC 07-168261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR402535Medicare Oscar/Certification