Basic Information
| Provider Information | |||||||||
| NPI: | 1730544081 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRO DE SALUD CONDUCTUAL MENONITA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLINICA AMBULATORIA DE OROCOVIS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 372800 | ||||||||
| Address2: | |||||||||
| City: | CAYEY | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007372800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7875351114 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 CALLE HOSPITAL CARRETERA 155 | ||||||||
| Address2: | |||||||||
| City: | OROCOVIS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7875951114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAZQUEZ | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7874341700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRO DE SALUD CONDUCTUAL MENONITA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.