1689619660 NPI number — CENTRO DE SERVICIOS MEDICOS DE PENA POBRE

Table of content: (NPI 1689619660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689619660 NPI number — CENTRO DE SERVICIOS MEDICOS DE PENA POBRE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO DE SERVICIOS MEDICOS DE PENA POBRE
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:
1689619660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
STREET 31
Provider Second Line Business Mailing Address:
192
Provider Business Mailing Address City Name:
NAGUABO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-874-3037
Provider Business Mailing Address Fax Number:
787-874-3037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
STREET 31
Provider Second Line Business Practice Location Address:
192
Provider Business Practice Location Address City Name:
NAGUABO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-874-3037
Provider Business Practice Location Address Fax Number:
787-874-3037
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POMALES
Authorized Official First Name:
GLADYS
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
787-874-3037

Provider Taxonomy Codes

  • Taxonomy code: 261QP0905X , with the licence number:  30673 , 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: 201648 . This is a "PREFERRED HEALTH" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 6701184 . This is a "HUMANA" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 9001119 . This is a "CRUZ AZUL DE PUERTO RICO" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 00409 . This is a "AMERICAN HEALTH" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 2991-1 . This is a "PROSAM" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 89681 . This is a "TRIPLE S" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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