1104808807 NPI number — CENTRO DE MEDICINE DE FAMILIA DE JUNCOS

Table of content: (NPI 1104808807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104808807 NPI number — CENTRO DE MEDICINE DE FAMILIA DE JUNCOS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO DE MEDICINE DE FAMILIA DE JUNCOS
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:
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:
1104808807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1569
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUNCOS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00777-1569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-734-4488
Provider Business Mailing Address Fax Number:
787-734-5460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PEDRO CRUZ MARGINAL #52 URB VALENCIA #1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUNCOS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-734-4488
Provider Business Practice Location Address Fax Number:
787-734-5460
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BERRIOS OCASIO
Authorized Official First Name:
NANNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICODE FAMILIA PRESIDENTE
Authorized Official Telephone Number:
787-734-4488

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  9865 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 067845 . This is a "CRUZ AZUL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 500097SE . This is a "MMM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6660041 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: PE2342 . This is a "PALIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34135 . This is a "PROSSAM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3471 . This is a "PREFERRED MEDICAL CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8230 . This is a "IMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200228 . This is a "UTI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 82139 . This is a "TRIPLE S" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3609865 . This is a "UIA" identifier . This identifiers is of the category "OTHER".




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