Provider Demographics
NPI:1215387691
Name:BEAU DERM LLC
Entity type:Organization
Organization Name:BEAU DERM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-484-2533
Mailing Address - Street 1:64 AVENIDA CONDADO
Mailing Address - Street 2:PLAZA DEL CONDADO 1202
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:516B CALLE JUAN J JIMENEZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-2605
Practice Address - Country:US
Practice Address - Phone:787-751-6018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19043261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service