Provider Demographics
NPI:1255758157
Name:DR. LUIS R FERMIN VALDEZ,CRL
Entity type:Organization
Organization Name:DR. LUIS R FERMIN VALDEZ,CRL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:RAFAEL
Authorized Official - Last Name:FERMIN VALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-347-4755
Mailing Address - Street 1:PO BOX 43002
Mailing Address - Street 2:SUITE 151
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-6601
Mailing Address - Country:US
Mailing Address - Phone:787-347-4755
Mailing Address - Fax:
Practice Address - Street 1:CALLE MAIN AA-4
Practice Address - Street 2:URB ALTURAS DE RIO GANDE
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-500-7270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11603261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR88969Medicare UPIN