1689106932 NPI number — CORPORACION FONDO SEGURO ESTADO AGUADILLA

Table of content: JESSE A BROYLES DO (NPI 1245895317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689106932 NPI number — CORPORACION FONDO SEGURO ESTADO AGUADILLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORPORACION FONDO SEGURO ESTADO AGUADILLA
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:
1689106932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 336
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AGUADILLA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00605-0336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-891-0805
Provider Business Mailing Address Fax Number:
787-882-4605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 2 KM 126.4
Provider Second Line Business Practice Location Address:
BO CAIMITAL BAJO
Provider Business Practice Location Address City Name:
AGUADILLA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-891-0805
Provider Business Practice Location Address Fax Number:
787-882-4605
Provider Enumeration Date:
03/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
FRANCISCO
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
787-891-0805

Provider Taxonomy Codes

  • Taxonomy code: 261QP0905X , with the licence number:  8543 , 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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