1164771853 NPI number — COLONIAL MEDICAL MANAGEMENT, CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164771853 NPI number — COLONIAL MEDICAL MANAGEMENT, CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL MEDICAL MANAGEMENT, CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164771853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1438
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RINCON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00677-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-826-8082
Provider Business Mailing Address Fax Number:
787-229-1091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 402 KM 1.8 BO MARIAS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANASCO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-826-8082
Provider Business Practice Location Address Fax Number:
787-229-1091
Provider Enumeration Date:
09/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ALICEA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
787-943-7889

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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