Basic Information
| Provider Information | |||||||||
| NPI: | 1619363397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENNONITE GENERAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRO DE SALUD CONDUCTUAL MENONITA CIMA AIBONITO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 871 | ||||||||
| Address2: | |||||||||
| City: | AIBONITO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007050871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7877353749 | ||||||||
| Practice Location | |||||||||
| Address1: | CALLE SARGENTO GERARDO SANTIAGO CARRETERA 14 INTERIOR | ||||||||
| Address2: | |||||||||
| City: | AIBONITO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007051379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875351001 | ||||||||
| FaxNumber: | 7875351114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VASQUEZ RIVERA | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTORA FACTYRACION Y COBRO | ||||||||
| AuthorizedOfficialTelephone: | 7654341700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 6 | 01 | PR | LICENCIA SALUD | OTHER |