Healthcare Provider Details

I. General information

NPI: 1699491050
Provider Name (Legal Business Name): MEDIPREV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRO COMERCIAL CIUDAD JARDIN LOCAL 1
BAYAMON PR
00956
US

IV. Provider business mailing address

DG15 CALLE BABILONIA
BAYAMON PR
00956-5342
US

V. Phone/Fax

Practice location:
  • Phone: 787-412-3346
  • Fax:
Mailing address:
  • Phone: 787-797-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARILLIAM JORGE
Title or Position: PRESIDENT
Credential:
Phone: 787-412-3346