Provider Demographics
NPI:1801115605
Name:AMANECER MUTUO, PSC
Entity type:Organization
Organization Name:AMANECER MUTUO, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOPEZ-CALERO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-453-0563
Mailing Address - Street 1:PO BOX 1893
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984-1893
Mailing Address - Country:US
Mailing Address - Phone:787-453-0563
Mailing Address - Fax:
Practice Address - Street 1:5725 BLVD. MEDIA LUNA, SUITE # 5
Practice Address - Street 2:GALERIAS DE ESCORIAL SHOPPING CENTER
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987
Practice Address - Country:US
Practice Address - Phone:787-453-0563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16005208D00000X
PR27511223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRBX187AOtherMEDICARE PTAN