Provider Demographics
NPI:1952739385
Name:PUERTO RICO PERFORMANCE MEDICAL GROUP
Entity type:Organization
Organization Name:PUERTO RICO PERFORMANCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUCIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUREANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-460-0538
Mailing Address - Street 1:F12 CALLE 1
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-3022
Mailing Address - Country:US
Mailing Address - Phone:787-460-1129
Mailing Address - Fax:
Practice Address - Street 1:1 F12 PRADO ALTO
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-460-1129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR219305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR305500000XOtherMANAGE CARE ORGANIZATION