Basic Information
| Provider Information | |||||||||
| NPI: | 1861703464 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN PABLO DEVELOPERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED IMAGING INTERVENTIONAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1186 | ||||||||
| Address2: | |||||||||
| City: | BAYAMON | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009601186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872692442 | ||||||||
| FaxNumber: | 7877859558 | ||||||||
| Practice Location | |||||||||
| Address1: | STREET 70 EDIFICIO DR ARTURO CADILLA | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BAYAMON | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009600102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872692442 | ||||||||
| FaxNumber: | 7877859558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2010 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERNAL | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7872692442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 83920 | 01 | PR | SSS | OTHER |