MEDICARE: ATLANTIS HEALTH CARE GROUP PUERTO RICO, 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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	#43	PR

General Provider Information

NPI Number	:	1952732596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIS HEALTH CARE GROUP PUERTO RICO, INC.

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

Provider Business Practice Location Address
First Line	:	CARR. #2 KM 156.5
Second Line	:	PISO 1 EDIF. OFFICE PARK IV
City	:	MAYAGUEZ
State	:	PR
Zip	:	00680-8123
Country	:	US
Telephone Number	:	787-292-7979
Fax Number	:	787-292-7999

Authorized Official
Title or Position	:	PRESIDENT, CEO
Name	:	MRS. RUBETTE HARFORD
Credential	:
Telephone Number	:	787-292-7979

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	12/09/2013

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