Provider Demographics
NPI:1790230399
Name:CENTRO QUIROPRACTICO DE MAYAGUEZ, CSP
Entity Type:Organization
Organization Name:CENTRO QUIROPRACTICO DE MAYAGUEZ, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:AVILES RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-265-4477
Mailing Address - Street 1:24 CALLE DUARTE
Mailing Address - Street 2:URB SAN JOSE
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-1133
Mailing Address - Country:US
Mailing Address - Phone:787-265-4477
Mailing Address - Fax:
Practice Address - Street 1:349 AVE HOSTOS
Practice Address - Street 2:MEDICAL EMPORIUM II, SUITE A33
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1509
Practice Address - Country:US
Practice Address - Phone:787-265-4477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty