Provider Demographics
NPI:1689018723
Name:BREAST CANCER CARE, CSP
Entity Type:Organization
Organization Name:BREAST CANCER CARE, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:I
Authorized Official - Last Name:RODRIGUEZ LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-651-6010
Mailing Address - Street 1:609 AVE TITO CASTRO
Mailing Address - Street 2:SUITE 102 PMB 464
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-0200
Mailing Address - Country:US
Mailing Address - Phone:787-651-6010
Mailing Address - Fax:787-651-6309
Practice Address - Street 1:TORRE MED SAN LUCAS
Practice Address - Street 2:, SUITES 508-509
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4728
Practice Address - Country:US
Practice Address - Phone:787-651-6010
Practice Address - Fax:787-651-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X, 261QI0500X, 261QX0200X
PR14399261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR14399OtherMEDICAL LICENSE