Provider Demographics
NPI:1609190610
Name:IMI OF SAN JUAN
Entity Type:Organization
Organization Name:IMI OF SAN JUAN
Other - Org Name:CAROLINA NUCLEAR & CARDIOVASCULAR INSTTUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUFFRONT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-757-5985
Mailing Address - Street 1:1448 AVE FERNANDEZ JUNCOS
Mailing Address - Street 2:
Mailing Address - City:SANTURCE
Mailing Address - State:PR
Mailing Address - Zip Code:00909-2655
Mailing Address - Country:US
Mailing Address - Phone:787-721-7776
Mailing Address - Fax:787-721-7774
Practice Address - Street 1:AVENUE MONSERRATE #AC8
Practice Address - Street 2:VALLE ARRIBA HEIGHTS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985-5444
Practice Address - Country:US
Practice Address - Phone:787-757-5985
Practice Address - Fax:787-757-6190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR52-25390-01261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR52-25390-01OtherNRC