Healthcare Provider Details

I. General information

NPI: 1518292986
Provider Name (Legal Business Name): MEDICOS SELECTOS DE P.R. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CALLE LEPANTO
SAN JUAN PR
00926-1905
US

IV. Provider business mailing address

PO BOX 801293
COTO LAUREL PR
00780-1293
US

V. Phone/Fax

Practice location:
  • Phone: 787-717-5655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: JOSE L MUNDO SR.
Title or Position: TESORERO
Credential:
Phone: 787-717-5655