Healthcare Provider Details

I. General information

NPI: 1689106932
Provider Name (Legal Business Name): CORPORACION FONDO SEGURO ESTADO AGUADILLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 2 KM 126.4 BO CAIMITAL BAJO
AGUADILLA PR
00603
US

IV. Provider business mailing address

PO BOX 336
AGUADILLA PR
00605-0336
US

V. Phone/Fax

Practice location:
  • Phone: 787-891-0805
  • Fax: 787-882-4605
Mailing address:
  • Phone: 787-891-0805
  • Fax: 787-882-4605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number8543
License Number StatePR

VIII. Authorized Official

Name: JUAN FRANCISCO HERNANDEZ
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 787-891-0805