Provider Demographics
NPI:1821342957
Name:CDT HORMIGUEROS PREVENTIVE MEDICINE, INC
Entity Type:Organization
Organization Name:CDT HORMIGUEROS PREVENTIVE MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVERA JAUME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-484-8273
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-5550
Mailing Address - Country:US
Mailing Address - Phone:787-935-7103
Mailing Address - Fax:787-935-7301
Practice Address - Street 1:2 MUNOZ MARIN STREET
Practice Address - Street 2:
Practice Address - City:HORMIGUEROS
Practice Address - State:PR
Practice Address - Zip Code:00660-0000
Practice Address - Country:US
Practice Address - Phone:787-935-7103
Practice Address - Fax:787-935-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR32291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR32OtherLICENCIA DE LABORATORIO
PR40D2036452OtherLICENCIA DE CLIA