Healthcare Provider Details

I. General information

NPI: 1649477928
Provider Name (Legal Business Name): GLG PREVENTIVE MEDICINE CENTER,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SAN GERMAN MEDICAL PLAZA SUITE 202 RD #2 KM 176
SAN GERMAN PR
00683
US

IV. Provider business mailing address

PO BOX 923
HORMIGUEROS PR
00660-0923
US

V. Phone/Fax

Practice location:
  • Phone: 787-264-2124
  • Fax:
Mailing address:
  • Phone: 787-264-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number16660
License Number StatePR

VIII. Authorized Official

Name: GERMAN LUIS GONZALEZ GONZALEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-264-2124