Healthcare Provider Details

I. General information

NPI: 1003678830
Provider Name (Legal Business Name): CENTRO DE VACUNACION DE LA POLICLINICA DE ANASCO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 01/26/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 DE INFANTERIA #67 SUITE 104
ANASCO PR
00610
US

IV. Provider business mailing address

PO BOX 1750
ANASCO PR
00610-1750
US

V. Phone/Fax

Practice location:
  • Phone: 787-826-2145
  • Fax: 787-826-7411
Mailing address:
  • Phone: 787-826-2145
  • Fax: 787-826-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO J AYALA RIOS
Title or Position: PRESWIDENTE
Credential: MD
Phone: 787-370-6187