Healthcare Provider Details

I. General information

NPI: 1336407360
Provider Name (Legal Business Name): MIGRANT HEALTH CENTER WESTERN REGION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NUMERO 189 INTERIOR AVENIDA DUSCOME
MAYAGUEZ PR
00680-0000
US

IV. Provider business mailing address

PO BOX 190
MAYAGUEZ PR
00681-0190
US

V. Phone/Fax

Practice location:
  • Phone: 787-805-4870
  • Fax: 787-834-1924
Mailing address:
  • Phone: 787-805-7360
  • Fax: 787-834-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number575911
License Number StatePR

VIII. Authorized Official

Name: MR. REYNALDO SERRANO CARABALLO
Title or Position: DIRECTOR EJECUTIVO
Credential: MR.
Phone: 787-805-7360