Healthcare Provider Details

I. General information

NPI: 1851658249
Provider Name (Legal Business Name): PLAZA MAGNOLIA MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 10 O 13 MAGNOLIA GARDENS
BAYAMON PUERTO RICO
00956
UM

IV. Provider business mailing address

P. O. BOX 596
BAYAMON PUERTO RICO
00960
UM

V. Phone/Fax

Practice location:
  • Phone: 17872883805
  • Fax: 17872699600
Mailing address:
  • Phone: 17872883805
  • Fax: 17872699600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number11341
License Number StatePR

VIII. Authorized Official

Name: DR. MANUEL A. SANTIAGO PEREZ
Title or Position: OWNER
Credential: M.D.
Phone: 17872883805