MEDICARE: AFSC OF SAN JUAN, PSC

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	261QA1903X	Ambulatory Surgical Clinic/Center	16	PR

General Provider Information

NPI Number	:	1730582792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFSC OF SAN JUAN, PSC

Provider Business Mailing Address
First Line	:	PO BOX 19657
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00910-1657
Country	:	US
Telephone Number	:	787-724-0871
Fax Number	:	787-724-0886

Provider Business Practice Location Address
First Line	:	1413 AVE FERNANDEZ JUNCOS
Second Line	:	SUITE 1A
City	:	SAN JUAN
State	:	PR
Zip	:	00909-2649
Country	:	US
Telephone Number	:	787-724-0871
Fax Number	:	787-724-0886

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EGIDIO MONTANILE
Credential	:
Telephone Number	:	787-724-0871

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	10/06/2014

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