Basic Information
| Provider Information | |||||||||
| NPI: | 1225694037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENNONITE GENERAL HOSPITAL,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRO DE SALUD CONDUCTUAL MENONITA CIMA CAGUAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | URB BONNEVILLE HEIGHTS | ||||||||
| Address2: | F35 CALLE 2 BO PUEBLO | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341715 | ||||||||
| Practice Location | |||||||||
| Address1: | URB BONNEVILLE HEIGHTS | ||||||||
| Address2: | F35 AVE DEGATOU BO PUEBLO | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007250000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872969776 | ||||||||
| FaxNumber: | 7877353749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VASQUEZ RIVERA | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR BILLING AND COLLECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7877142462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 6 | 01 | PR | LICENCIA OPERACIONAL DEL DEPARTAMENTO DE SALUD | OTHER |