Provider Demographics
NPI:1699192336
Name:MAYAGUEZ SPORT MEDICINE L L C
Entity Type:Organization
Organization Name:MAYAGUEZ SPORT MEDICINE L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEREZ LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-464-2788
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0418
Mailing Address - Country:US
Mailing Address - Phone:787-652-3800
Mailing Address - Fax:787-652-3802
Practice Address - Street 1:875 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1529
Practice Address - Country:US
Practice Address - Phone:787-652-3800
Practice Address - Fax:787-652-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty