MEDICARE: MENNONITE GENERAL HOSPITAL 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6	OTHER	PR	LICENCIA OPERACIONAL DEL DEPARTAMENTO DE SALUD

General Provider Information

NPI Number	:	1225694037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENNONITE GENERAL HOSPITAL INC.

Provider Business Mailing Address
First Line	:	URB BONNEVILLE HEIGHTS
Second Line	:	F35 CALLE 2 BO PUEBLO
City	:	CAGUAS
State	:	PR
Zip	:	00725
Country	:	US
Telephone Number	:	787-434-1700
Fax Number	:	787-434-1715

Provider Business Practice Location Address
First Line	:	AVENIDA JOSE GAUTIER BENITEZ, NUMERO 230 BO. PUEBLO
Second Line	:
City	:	CAGUAS
State	:	PR
Zip	:	00725-5546
Country	:	US
Telephone Number	:	787-296-9776
Fax Number	:	787-735-3749

Authorized Official
Title or Position	:	DIRECTOR BILLING AND COLLECTOR
Name	:	LISSETTE VASQUEZ RIVERA
Credential	:
Telephone Number	:	787-714-2462

Provider Enumeration Date	:	05/16/2019
Last Update Date	:	01/24/2025

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