Healthcare Provider Details

I. General information

NPI: 1649719824
Provider Name (Legal Business Name): CORPORACION FONDO DEL SEGURO DEL ESTADO BAYAMON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA ESTATAL 2 KM 8.5
BAYAMON PR
00960
US

IV. Provider business mailing address

CARR ESTATAL 2 KM 8.5 BO JUAN SANCHEZ
BAYAMON PR
00960-0248
US

V. Phone/Fax

Practice location:
  • Phone: 787-782-8250
  • Fax: 787-782-8208
Mailing address:
  • Phone: 787-782-8250
  • Fax: 787-782-8208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number120
License Number StatePR

VIII. Authorized Official

Name: DR. MARIA I LASTRA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 787-782-8250