Healthcare Provider Details

I. General information

NPI: 1255450441
Provider Name (Legal Business Name): CENTRO ESPECIALISTA DE MEDICINA DEL ESTE C S P
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. FONT MARTELO # 334
HUMACAO PR
00792
US

IV. Provider business mailing address

PO BOX 428
HUMACAO PR
00792-0428
US

V. Phone/Fax

Practice location:
  • Phone: 787-852-0886
  • Fax: 787-852-0280
Mailing address:
  • Phone: 787-852-0886
  • Fax: 787-852-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number10627
License Number StatePR

VIII. Authorized Official

Name: DR. AGUSTIN JUAN LOPEZ- COVAS
Title or Position: DIRECTOR
Credential: M.D.
Phone: 787-852-0886