MEDICARE: CENTRO DE MEDICINA INTEGRAL DE MANATI,INC

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	261QP0904X	Federal Public Health Clinic/Center

General Provider Information

NPI Number	:	1043675622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE MEDICINA INTEGRAL DE MANATI,INC

Provider Business Mailing Address
First Line	:	PO BOX 4317
Second Line	:
City	:	VEGA BAJA
State	:	PR
Zip	:	00694-4317
Country	:	US
Telephone Number	:	787-884-4700
Fax Number	:	787-884-9719

Provider Business Practice Location Address
First Line	:	77 BO COTTO
Second Line	:	URBANIZACION FELIX CORDOVA DAVILA
City	:	MANATI
State	:	PR
Zip	:	00674-0000
Country	:	US
Telephone Number	:	787-884-4700
Fax Number	:	787-884-9719

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MILDALIAS DOMINGUEZ PASCUAL
Credential	:	MD
Telephone Number	:	787-884-4700

Provider Enumeration Date	:	12/23/2015
Last Update Date	:	12/23/2015

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