Healthcare Provider Details

I. General information

NPI: 1407097744
Provider Name (Legal Business Name): CENTRO DE CONSULTORIA MEDICA,CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SS RODRIGUEZ 57 B
GUANICA PR
00653
US

IV. Provider business mailing address

57 SS RODRIGUEZ
GUANICA PR
00653
US

V. Phone/Fax

Practice location:
  • Phone: 787-821-6565
  • Fax: 787-821-6565
Mailing address:
  • Phone: 787-821-6565
  • Fax: 787-821-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number16824
License Number StatePR

VIII. Authorized Official

Name: DR. JUAN C MONTALVO
Title or Position: PRESIDENT
Credential: M. D.
Phone: 787-821-6565