Provider Demographics
NPI:1740413590
Name:CENTRO QUIRURGICO DE LA MONTANA INC
Entity Type:Organization
Organization Name:CENTRO QUIRURGICO DE LA MONTANA INC
Other - Org Name:GRUPO DE CIRUJANOS CQM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-535-0380
Mailing Address - Street 1:PO BOX 371358
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00737-1358
Mailing Address - Country:US
Mailing Address - Phone:787-535-0380
Mailing Address - Fax:787-535-0363
Practice Address - Street 1:174 CALLE LUIS BARRERAS S
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-4615
Practice Address - Country:US
Practice Address - Phone:787-535-0380
Practice Address - Fax:787-535-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10OtherLICENSE
PR10OtherLICENSE