Healthcare Provider Details

I. General information

NPI: 1174079537
Provider Name (Legal Business Name): PHM MULTIDISCIPLINARY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 CALLE ALDA SUITE 201
SAN JUAN PR
00926-2709
US

IV. Provider business mailing address

1551 CALLE ALDA SUITE 201 URB. CARIBE
SAN JUAN PR
00926-2709
US

V. Phone/Fax

Practice location:
  • Phone: 787-625-2500
  • Fax: 787-625-0294
Mailing address:
  • Phone: 787-650-2732
  • Fax: 787-650-2734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WALESKA MARRERO
Title or Position: MEDICAL AND HEALTH SERVICES DIRECTO
Credential: LCDA
Phone: 717-407-8764