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General NPI Number Information
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NPI Number | 1609190610
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Entity Type | Organization
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Legal Business Name | IMI OF SAN JUAN
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Dates
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Enumeration Date | 03/19/2010
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Last Update Date | 03/31/2010
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Provider Practice Location Address
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Address Line | AVENUE MONSERRATE #AC8 VALLE ARRIBA HEIGHTS
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City | CAROLINA
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State | PR
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Zip | 00985-5444
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Country | US
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Telephone | 787-757-5985
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Fax | 787-757-6190
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Provider Business Mailing Address
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Address Line | 1448 AVE FERNANDEZ JUNCOS
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City | SANTURCE
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State | PR
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Zip | 00909-2655
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Country | US
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Telephone | 787-721-7776
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Fax | 787-721-7774
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Authorized Official
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Title or Position | CENTER DIRECTOR
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Name | MS. NIVIA SOUFFRONT
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Credential |
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Telephone | 787-757-5985
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 52-25390-01
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License Number State | PR
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