Healthcare Provider Details

I. General information

NPI: 1639393697
Provider Name (Legal Business Name): IPA POLICLINICA VILLA LOS SANTOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

V1 CALLE 16 URB. VILLA LOS SANTOS
ARECIBO PR
00612-3112
US

IV. Provider business mailing address

PO BOX 9091 COTTO STATION
ARECIBO PR
00613-9091
US

V. Phone/Fax

Practice location:
  • Phone: 787-879-1585
  • Fax: 787-879-4315
Mailing address:
  • Phone: 787-879-1585
  • Fax: 787-879-4315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARIA GONZALEZ AGRASO
Title or Position: ADMINISTRADORA
Credential: M.D.
Phone: 787-817-3144