Provider Demographics
NPI:1205803210
Name:CLINICA DE MEDICINA DEPORTIVA DEL CARIBE INC.
Entity type:Organization
Organization Name:CLINICA DE MEDICINA DEPORTIVA DEL CARIBE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-721-4643
Mailing Address - Street 1:DEL PARQUE STREET 110 BALMORAL BLDG
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00911
Mailing Address - Country:US
Mailing Address - Phone:787-721-4643
Mailing Address - Fax:787-723-8664
Practice Address - Street 1:110 CALLE DEL PARQUE
Practice Address - Street 2:BALMORAL BLDG 1ST FLOOR
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00911-1901
Practice Address - Country:US
Practice Address - Phone:787-723-4857
Practice Address - Fax:787-723-8664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0028082Medicare ID - Type Unspecified