1194750588 NPI number — FAJARDO HOME CARE PROGRAM, INC.

Table of content: (NPI 1194750588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194750588 NPI number — FAJARDO HOME CARE PROGRAM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAJARDO HOME CARE PROGRAM, INC.
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:
CUIDADO CASERO FAJARDO
Provider Other Organization Name Type Code:
3
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:
1194750588
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 N CARROLL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-5306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-310-1100
Provider Business Mailing Address Fax Number:
817-310-1197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 AVE GENERAL VALERO
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
FAJARDO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00738-4893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-868-6361
Provider Business Practice Location Address Fax Number:
787-850-5270
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANTIAGO
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
817-310-1100

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  11621 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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