Basic Information
| Provider Information | |||||||||
| NPI: | 1619074093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALMETTO SERVICES PSC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCE EMERGENCY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GRAN BULEVARD PASEOS | ||||||||
| Address2: | SUITE 112-297 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872920600 | ||||||||
| FaxNumber: | 7877612094 | ||||||||
| Practice Location | |||||||||
| Address1: | SALA EMERGENCIA HIMA | ||||||||
| Address2: | AVE. LUIS MUNOZ MARIN, ESQ. DEGETAU | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876533434 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEPULVEDA | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7872920600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.