Provider Demographics
NPI:1972806537
Name:SERVICIOS MEDICOS ILUMINA-TUS, CSP
Entity Type:Organization
Organization Name:SERVICIOS MEDICOS ILUMINA-TUS, CSP
Other - Org Name:ILUMINA-TUS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLON-SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-604-4589
Mailing Address - Street 1:352 CALLE DEL PARQUE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00912-3702
Mailing Address - Country:US
Mailing Address - Phone:787-723-5574
Mailing Address - Fax:787-721-4035
Practice Address - Street 1:2069 CALLE BUENOS AIRES
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00911-1756
Practice Address - Country:US
Practice Address - Phone:787-723-5574
Practice Address - Fax:787-721-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X, 171M00000X, 302F00000X
PR261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Multi-Specialty