Healthcare Provider Details

I. General information

NPI: 1407852338
Provider Name (Legal Business Name): LIGA PUERTORRIQUENA CONTRA EL CANCER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO MONACILLOS 150 AVE AMERICO MIRANDA AREA CENTRO MEDICO METROPOLITANO
SAN JUAN PR
00935-0001
US

IV. Provider business mailing address

PO BOX 191811
SAN JUAN PR
00919-1811
US

V. Phone/Fax

Practice location:
  • Phone: 787-763-4149
  • Fax: 787-641-4601
Mailing address:
  • Phone: 787-763-4149
  • Fax: 787-641-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number#65
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. JORGE DE JESUS ROZAS SR.
Title or Position: EXECUTIVE DIRECTOR
Credential: MHSA
Phone: 787-763-4149