Basic Information
| Provider Information | |||||||||
| NPI: | 1154379253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRO DE RADIOTERAPIA AUXILIO MUTUO, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191227 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877717934 | ||||||||
| FaxNumber: | 7877717402 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 AVE PONCE DE LEON | ||||||||
| Address2: | STOP 37.5 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009175022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877717934 | ||||||||
| FaxNumber: | 7877717402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | MATTA | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | LUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7877582000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MHSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 7582 | 01 | PR | PALIC | OTHER | 9190184 | 01 | PR | HUMANA | OTHER | 100593 | 01 | PR | CRUZ AZUL | OTHER | 660312302 | 01 | PR | MAPFRE | OTHER |