Provider Demographics
NPI:1598475154
Name:CANOVANAS X RAY
Entity Type:Organization
Organization Name:CANOVANAS X RAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINITRADORA
Authorized Official - Prefix:
Authorized Official - First Name:GREGMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:939-274-9637
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-2003
Mailing Address - Country:US
Mailing Address - Phone:787-876-5000
Mailing Address - Fax:
Practice Address - Street 1:AVE CORCHADO FINAL
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729-0000
Practice Address - Country:US
Practice Address - Phone:787-876-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:66-0841749
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-05
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PROG682Medicaid