Provider Demographics
NPI:1063945996
Name:SPORTMED INTERNATIONAL, LLC.
Entity type:Organization
Organization Name:SPORTMED INTERNATIONAL, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:NAZARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-534-3062
Mailing Address - Street 1:S3-11 CARR 21 SUITE 301
Mailing Address - Street 2:URB LAS LOMAS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921
Mailing Address - Country:US
Mailing Address - Phone:787-534-3062
Mailing Address - Fax:
Practice Address - Street 1:U12 CALLE 10
Practice Address - Street 2:ALTURAS DE FLAMBOYAN
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-8052
Practice Address - Country:US
Practice Address - Phone:787-534-3062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service