Healthcare Provider Details

I. General information

NPI: 1679781322
Provider Name (Legal Business Name): GRUPO ADVANTAGE DEL OESTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 CALLE ALDA SUITE 201 URB. CARIBE
SAN JUAN PR
00926-2709
US

IV. Provider business mailing address

1551 CALLE ALDA SUITE 201 URB. CARIBE
SAN JUAN PR
00926-2709
US

V. Phone/Fax

Practice location:
  • Phone: 787-281-0810
  • Fax: 787-474-3051
Mailing address:
  • Phone: 787-281-0810
  • Fax: 787-474-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO LUIS BENGO
Title or Position: PRESIDENT
Credential:
Phone: 787-281-0810