Healthcare Provider Details

I. General information

NPI: 1043675622
Provider Name (Legal Business Name): CENTRO DE MEDICINA INTEGRAL DE MANATI,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 BO COTTO URBANIZACION FELIX CORDOVA DAVILA
MANATI PR
00674-0000
US

IV. Provider business mailing address

PO BOX 4317
VEGA BAJA PR
00694-4317
US

V. Phone/Fax

Practice location:
  • Phone: 787-884-4700
  • Fax: 787-884-9719
Mailing address:
  • Phone: 787-884-4700
  • Fax: 787-884-9719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MILDALIAS DOMINGUEZ PASCUAL
Title or Position: PRESIDENT
Credential: MD
Phone: 787-884-4700