Provider Demographics
NPI:1053602029
Name:CENTRO DE DIALISIS SAN MIGUEL ARCANGEL, LLC
Entity type:Organization
Organization Name:CENTRO DE DIALISIS SAN MIGUEL ARCANGEL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-604-7744
Mailing Address - Street 1:405 ESMERALDA AVENUE
Mailing Address - Street 2:SUITE 174
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-604-7744
Mailing Address - Fax:787-782-7447
Practice Address - Street 1:ROAD 164, KM 7.1
Practice Address - Street 2:
Practice Address - City:NARANJITO
Practice Address - State:PR
Practice Address - Zip Code:00719
Practice Address - Country:US
Practice Address - Phone:787-227-4604
Practice Address - Fax:787-782-7447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment