MEDICARE: POLICLINICA DEL CARIBE PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	5572	PR

General Provider Information

NPI Number	:	1003218637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLICLINICA DEL CARIBE PSC

Provider Business Mailing Address
First Line	:	PO BOX 3677
Second Line	:
City	:	CAROLINA
State	:	PR
Zip	:	00984-3677
Country	:	US
Telephone Number	:	787-791-5712
Fax Number	:	787-253-3689

Provider Business Practice Location Address
First Line	:	41 CALLE PISCIS
Second Line	:	LOS ANGELES
City	:	CAROLINA
State	:	PR
Zip	:	00979-1620
Country	:	US
Telephone Number	:	787-791-5712
Fax Number	:	787-253-3689

Authorized Official
Title or Position	:	PRESIDENTE
Name	:	DR. JORGE LUIS MENDEZ SANTIAGO
Credential	:	M.D.
Telephone Number	:	787-791-5712

Provider Enumeration Date	:	09/26/2014
Last Update Date	:	09/26/2014

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