Provider Demographics
NPI:1184363459
Name:WEST SIDE LLC
Entity type:Organization
Organization Name:WEST SIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABIMELEC
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTALATIN PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-718-2284
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:PR
Mailing Address - Zip Code:00690-0310
Mailing Address - Country:US
Mailing Address - Phone:787-718-2284
Mailing Address - Fax:
Practice Address - Street 1:CARR 459 KM 1.8 INT
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-718-2284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty