Provider Demographics
NPI:1245309665
Name:ARARAT LIPODYSTROPHY CLINIC, INC
Entity type:Organization
Organization Name:ARARAT LIPODYSTROPHY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCECUTIVE DIRECTOS
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:787-284-5884
Mailing Address - Street 1:8169 CALLE CONCORDIA STE 411
Mailing Address - Street 2:COND. SAN VICENTE
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1567
Mailing Address - Country:US
Mailing Address - Phone:787-284-5884
Mailing Address - Fax:787-284-5874
Practice Address - Street 1:8169 CALLE CONCORDIA STE 411
Practice Address - Street 2:COND. SAN VICENTE
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1567
Practice Address - Country:US
Practice Address - Phone:787-284-5884
Practice Address - Fax:787-284-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12061207Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center