Healthcare Provider Details

I. General information

NPI: 1134873235
Provider Name (Legal Business Name): PUERTO RICO PRIMARY CARE MSO, INC. - CDT LUQUILLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 14 DE JULIO NO 159 BO MATA DE PLATANO
LUQUILLO PR
00773
US

IV. Provider business mailing address

PO BOX 818
CEIBA PR
00735-0818
US

V. Phone/Fax

Practice location:
  • Phone: 787-885-4446
  • Fax: 787-885-6129
Mailing address:
  • Phone: 787-534-3789
  • Fax: 787-885-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEILA CENTENO
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-534-3789