Healthcare Provider Details

I. General information

NPI: 1679876718
Provider Name (Legal Business Name): GALENOS SELECTOS DE PUERTO RICO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZOLETA PONCE CASH AND CARRY MORELL CAMPOS LOCAL 4
PONCE PR
00732
US

IV. Provider business mailing address

PMB 261 BOX 7105
PONCE PUERTO RICO
00732
UM

V. Phone/Fax

Practice location:
  • Phone: 787-284-1566
  • Fax: 787-290-6689
Mailing address:
  • Phone: 787-284-1566
  • Fax: 787-290-6689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number11B2134
License Number StatePR

VIII. Authorized Official

Name: DR. EFRAIN DIEGO GONZALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 916-990-4204