Healthcare Provider Details

I. General information

NPI: 1932136470
Provider Name (Legal Business Name): POLICLINICA LA FAMILIA TOA ALTA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10ST #G-21, URB. VILLA MATILDE
TOA ALTA PR
00953
US

IV. Provider business mailing address

PO BOX 867
TOA ALTA PR
00954-0867
US

V. Phone/Fax

Practice location:
  • Phone: 787-870-7070
  • Fax: 787-870-6382
Mailing address:
  • Phone: 787-870-7070
  • Fax: 787-870-6382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number13168
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14703
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number7078
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number14247
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number10413
License Number StatePR
# 6
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number5109
License Number StatePR
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2532
License Number StatePR
# 8
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number9462
License Number StatePR

VIII. Authorized Official

Name: DR. ITZA D CHEVRES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-870-7121