Healthcare Provider Details

I. General information

NPI: 1720505548
Provider Name (Legal Business Name): PHM MULTIDISCIPLINARY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO. VICTORIA CARRETERA 2 KM 129.3
AGUADILLA PR
00603
US

IV. Provider business mailing address

1551 CALLE ALDA
SAN JUAN PR
00926-2709
US

V. Phone/Fax

Practice location:
  • Phone: 787-658-1389
  • Fax: 787-658-1392
Mailing address:
  • Phone: 787-658-1389
  • Fax: 787-658-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MR. WALESKA MARRERO
Title or Position: MEDICAL AND HEALTH SERVICES DIRECTO
Credential:
Phone: 787-407-8764