Healthcare Provider Details

I. General information

NPI: 1831302173
Provider Name (Legal Business Name): POLICLINICA FAMILIAR SHALOM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO TERRANOVA CALLE MARGINAL DEL PARQUE
QUEBRADILLAS PR
00678
US

IV. Provider business mailing address

PO BOX 903
QUEBRADILLAS PR
00678-0903
US

V. Phone/Fax

Practice location:
  • Phone: 787-895-0914
  • Fax:
Mailing address:
  • Phone: 787-895-0914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number145
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11789
License Number StatePR

VIII. Authorized Official

Name: MR. IVAN FELICIANO
Title or Position: SUPERVISOR
Credential:
Phone: 787-291-0991