=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659836542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO DE SALUD FAMILIAR MENONITA CULEBRA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2019
-----------------------------------------------------
Last Update Date | 02/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE WILLIAM FONT
-----------------------------------------------------
City | CULEBRA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00775-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-434-1700
-----------------------------------------------------
Fax | 787-434-1715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1650
-----------------------------------------------------
City | CIDRA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00739-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-434-1700
-----------------------------------------------------
Fax | 787-434-1715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | LISSETTE VASQUEZ RIVERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-653-0550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------