Healthcare Provider Details

I. General information

NPI: 1093069122
Provider Name (Legal Business Name): CDT HORMIGUEROS PREVENTIVE MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MUNOZ RIVERA STREET
HORMIGUEROS PR
00660-0000
US

IV. Provider business mailing address

PO BOX 1550
HORMIGUEROS PR
00660-5550
US

V. Phone/Fax

Practice location:
  • Phone: 787-935-7103
  • Fax: 787-935-7301
Mailing address:
  • Phone: 787-935-7103
  • Fax: 787-935-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number32
License Number StatePR

VIII. Authorized Official

Name: MR. JIMMY OLIVERA JAUME
Title or Position: ADMINISTRADOR
Credential:
Phone: 787-484-8273