1639509714 NPI number — ATLANTIS HEALTH CARE GROUP PUERTO RICO, INC.

Table of content: (NPI 1639509714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639509714 NPI number — ATLANTIS HEALTH CARE GROUP PUERTO RICO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTIS HEALTH CARE GROUP PUERTO RICO, 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:
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:
1639509714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1350
Provider Second Line Business Mailing Address:
ST. JUST STATION
Provider Business Mailing Address City Name:
TRUJILLO ALTO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00977-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-292-7979
Provider Business Mailing Address Fax Number:
787-292-7999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BO. BAHOMAMEY
Provider Second Line Business Practice Location Address:
AVE. EMERITO ESTADA KM 21.8 PR-125
Provider Business Practice Location Address City Name:
SAN SEBASTIAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00685-2285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-292-7979
Provider Business Practice Location Address Fax Number:
787-292-7999
Provider Enumeration Date:
11/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HARFORD
Authorized Official First Name:
RUBETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, CEO
Authorized Official Telephone Number:
787-292-7979

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  #37 , 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)

  • Identifier: 038203000 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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