Healthcare Provider Details

I. General information

NPI: 1194009423
Provider Name (Legal Business Name): ASSMCA PONCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL SAN LUCAS CARR 14
PONCE PR
00732
US

IV. Provider business mailing address

PO BOX 607087
BAYAMON PR
00960
US

V. Phone/Fax

Practice location:
  • Phone: 787-763-7575
  • Fax:
Mailing address:
  • Phone: 787-763-7575
  • Fax: 787-995-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LUIS MARTINEZ SUAREZ
Title or Position: ADMINISTRADOR
Credential:
Phone: 787-766-7575