=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316911241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN PABLO FAMILY PRACTICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2006
-----------------------------------------------------
Last Update Date | 07/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 CALLE SANTA CRUZ GALERIA MEDICA SUITE 103
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00961-6910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-780-8444
-----------------------------------------------------
Fax | 787-780-8444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 CALLE OZAMA URB. RIO PIEDRAS HEIGHTS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-764-1818
-----------------------------------------------------
Fax | 787-780-8444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSE E RIVERA MATTEI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-780-8444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 11712
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------