Provider Demographics
NPI:1710370630
Name:SPORTS MEDICINE CAGUAS, LLC.
Entity Type:Organization
Organization Name:SPORTS MEDICINE CAGUAS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-306-0118
Mailing Address - Street 1:35 JUAN C. BORBON STE 67
Mailing Address - Street 2:PMB 327
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-704-0033
Mailing Address - Fax:787-704-0090
Practice Address - Street 1:201 GAUTIER BENITEZ AVE
Practice Address - Street 2:CONSOLIDATED MEDICAL PLAZA STE 305
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-704-0033
Practice Address - Fax:787-704-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG73671Medicare UPIN