Healthcare Provider Details

I. General information

NPI: 1083993745
Provider Name (Legal Business Name): CENTRO DE VACUNACION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MUNOZ RIVERA # 3
CAGUAS PR
00725-1357
US

IV. Provider business mailing address

P O BOB 1357
CAGUAS PR
00726-1357
US

V. Phone/Fax

Practice location:
  • Phone: 787-552-1219
  • Fax: 787-745-0108
Mailing address:
  • Phone: 787-552-1219
  • Fax: 787-745-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERTO J GANDARA
Title or Position: PRESIDENTE
Credential: MD
Phone: 787-552-1219