Healthcare Provider Details

I. General information

NPI: 1023360070
Provider Name (Legal Business Name): JEZREELCITAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO. FLORIDA CARRETERA 183 RAMAL 9929 KM 1.6
SAN LORENZO PR
00754-0000
US

IV. Provider business mailing address

PO BOX 987
SAN LORENZO PR
00754-0987
US

V. Phone/Fax

Practice location:
  • Phone: 787-370-5021
  • Fax: 787-715-2221
Mailing address:
  • Phone: 787-370-5021
  • Fax: 787-715-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberPCVTE 4440
License Number StatePR

VIII. Authorized Official

Name: MR. OSVALDO ORTIZ
Title or Position: PESIDENT
Credential:
Phone: 787-370-5021