Healthcare Provider Details

I. General information

NPI: 1285855411
Provider Name (Legal Business Name): CANOVANAS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 CALLE PALMER
CANOVANAS PR
00729-3116
US

IV. Provider business mailing address

PO BOX 525
CANOVANAS PR
00729-0525
US

V. Phone/Fax

Practice location:
  • Phone: 787-256-7642
  • Fax: 787-876-5260
Mailing address:
  • Phone: 787-256-7642
  • Fax: 787-876-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number StatePR

VIII. Authorized Official

Name: MS. HILDA V MUJICA
Title or Position: PRESIDENTA
Credential: M.D.
Phone: 787-256-7642