Healthcare Provider Details

I. General information

NPI: 1154899128
Provider Name (Legal Business Name): PHM MULTIDISCIPLINARY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

B11 CALLE 2 URBANIZACION VILLA REAL
VEGA BAJA PR
00693
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 787-858-1156
  • Fax:
Mailing address:
  • Phone: 787-650-2732
  • Fax: 787-650-2734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO LUIS BENGOA
Title or Position: PRESIDENTE
Credential:
Phone: 787-625-2500