Provider Demographics
NPI:1720525389
Name:TOLENTINO, MILDRED
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:TOLENTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 AVE CASIANO CEPEDA
Mailing Address - Street 2:BO LAS DOLORES
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-2325
Mailing Address - Country:US
Mailing Address - Phone:787-674-5616
Mailing Address - Fax:
Practice Address - Street 1:300 AVENIDA CASIANO CEPEDA ESQUINA BRAZIL
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745-2325
Practice Address - Country:US
Practice Address - Phone:787-674-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4013610172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver