Provider Demographics
NPI:1760250039
Name:BURGOS MEDINA, JAVIER
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:BURGOS MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CALLE 7
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:PR
Mailing Address - Zip Code:00690-1345
Mailing Address - Country:US
Mailing Address - Phone:787-246-4059
Mailing Address - Fax:
Practice Address - Street 1:180 CALLE 7
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:PR
Practice Address - Zip Code:00690-1345
Practice Address - Country:US
Practice Address - Phone:787-246-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach