Provider Demographics
NPI:1285300251
Name:PUERTO RICO SKIN & LASER LLC
Entity type:Organization
Organization Name:PUERTO RICO SKIN & LASER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NOELANI
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:787-473-0073
Mailing Address - Street 1:120 AVE CARLOS CHARDON STE 133
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-1721
Mailing Address - Country:US
Mailing Address - Phone:787-473-0073
Mailing Address - Fax:
Practice Address - Street 1:525 AVE FD ROOSEVELT STE 409
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-8081
Practice Address - Country:US
Practice Address - Phone:787-473-0073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1187256-0010OtherREGISTRO DE COMERCIANTE
PR446563OtherCERTIFICATE OF ORGANIZATION