Provider Demographics
NPI:1962364919
Name:BAM PUERTO RICO
Entity type:Organization
Organization Name:BAM PUERTO RICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO RUSSE
Authorized Official - Suffix:
Authorized Official - Credentials:LND
Authorized Official - Phone:787-510-9452
Mailing Address - Street 1:452 AVE HOSTOS
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3062
Mailing Address - Country:US
Mailing Address - Phone:787-410-9201
Mailing Address - Fax:
Practice Address - Street 1:452 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3062
Practice Address - Country:US
Practice Address - Phone:787-410-9201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-28
Last Update Date:2025-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health