MEDICARE: MIGRANT HEALTH CENTER WESTERN REGION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1000X	Migrant Health Clinic/Center	575911	PR

General Provider Information

NPI Number	:	1336407360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIGRANT HEALTH CENTER WESTERN REGION, INC.

Provider Business Mailing Address
First Line	:	PO BOX 190
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00681-0190
Country	:	US
Telephone Number	:	787-805-7360
Fax Number	:	787-834-1924

Provider Business Practice Location Address
First Line	:	NUMERO 189 INTERIOR
Second Line	:	AVENIDA DUSCOME
City	:	MAYAGUEZ
State	:	PR
Zip	:	00680-0000
Country	:	US
Telephone Number	:	787-805-4870
Fax Number	:	787-834-1924

Authorized Official
Title or Position	:	DIRECTOR EJECUTIVO
Name	:	MR. REYNALDO SERRANO CARABALLO
Credential	:	MR.
Telephone Number	:	787-805-7360

Provider Enumeration Date	:	04/27/2012
Last Update Date	:	04/27/2012

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