Healthcare Provider Details

I. General information

NPI: 1326586546
Provider Name (Legal Business Name): CORPORACION FONDO SEGURO ESTADO FAJARDO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 AVE MARCELITO GOTAY SECTOR EL BATEY
FAJARDO PR
00738
US

IV. Provider business mailing address

460 AVE MARCELITO GOTAY
FAJARDO PR
00738-1207
US

V. Phone/Fax

Practice location:
  • Phone: 787-793-5959
  • Fax: 787-801-2900
Mailing address:
  • Phone: 787-793-5959
  • Fax: 787-801-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number9607
License Number StatePR

VIII. Authorized Official

Name: IRMA SANTOS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 787-793-5959