Healthcare Provider Details

I. General information

NPI: 1992415343
Provider Name (Legal Business Name): VILLA LOS SANTOS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VILLA LOS SANTOS CALLE 16 V 1
ARECIBO PR
00612
US

IV. Provider business mailing address

PO BOX 9091
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 TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA J GONZALEZ AGRASO
Title or Position: ADMINISTRADORA
Credential:
Phone: 787-879-1585