Healthcare Provider Details

I. General information

NPI: 1720364904
Provider Name (Legal Business Name): INTEGRA TOTAL MANAGE CARE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PONCE DE LEON AVENUE 402 UNION PLAZA BLD. SUITE 802
SAN JUAN PR
00917
US

IV. Provider business mailing address

PO BOX 367312
SAN JUAN PR
00936-7312
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-3206
  • Fax: 787-772-4724
Mailing address:
  • Phone: 787-758-3206
  • Fax: 787-772-4724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTOR HERNANDEZ
Title or Position: PRESIDENT
Credential: M.D. LIC. 11034
Phone: 787-307-3399