=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881254498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN MEDICAL GROUP P.S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2019
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PLAZA ANIDEM SUITE 3 CARR 447 KM 3.9 BARRIO AIBONITO
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685-9770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-896-5738
-----------------------------------------------------
Fax | 787-896-5738
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 1 BOX 11465
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685-9770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-896-5738
-----------------------------------------------------
Fax | 787-896-5738
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR MEDICO / PRESIDENTE
-----------------------------------------------------
Name | DR. CRISTOBAL I MENDEZ RUIZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-896-5738
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------