Healthcare Provider Details

I. General information

NPI: 1538310040
Provider Name (Legal Business Name): IPA 508 BELAVAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 AVE BORINQUEN
SAN JUAN PR
00915-3814
US

IV. Provider business mailing address

PO BOX 14457
SAN JUAN PR
00916-4457
US

V. Phone/Fax

Practice location:
  • Phone: 787-268-4171
  • Fax: 787-727-3695
Mailing address:
  • Phone: 787-268-4171
  • Fax: 787-727-3695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number156
License Number StatePR

VIII. Authorized Official

Name: MISS DAMARIS FLORES
Title or Position: HEALTH EDUCATOR
Credential:
Phone: 787-268-4171