Provider Demographics
NPI:1871149062
Name:MED BOUTIQUE
Entity type:Organization
Organization Name:MED BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:CONTY
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:787-794-5100
Mailing Address - Street 1:1705 CALLE EDUVIJES
Mailing Address - Street 2:URB SAGRADO CORAZON
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-519-9245
Mailing Address - Fax:787-794-5100
Practice Address - Street 1:D16 CALLE BUEN SAMARITANO
Practice Address - Street 2:URB GARDENVILLE
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-794-5100
Practice Address - Fax:787-794-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty