Basic Information
Provider Information | |||||||||
NPI: | 1740707314 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRO FAMILIAR MENONITA ARROYO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOSPITAL MENONITA GUAYAMA INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1650 | ||||||||
Address2: |   | ||||||||
City: | CIDRA | ||||||||
State: | PR | ||||||||
PostalCode: | 007391650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874341700 | ||||||||
FaxNumber: | 7874371714 | ||||||||
Practice Location | |||||||||
Address1: | CARRETERA 753 SECTOR CUATRO CALLES | ||||||||
Address2: |   | ||||||||
City: | ARROYO | ||||||||
State: | PR | ||||||||
PostalCode: | 00714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874341700 | ||||||||
FaxNumber: | 7874341714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2017 | ||||||||
LastUpdateDate: | 06/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VAZQUEZ RIVERA | ||||||||
AuthorizedOfficialFirstName: | LISSETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING AND CODING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7874341700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HOSPITAL MENONITA GUAYAMA INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 17-086 | PR | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
ID | Type | State | Issuer | Description | 66087682 | 05 | PR |   | MEDICAID | 400048 | 05 | PR |   | MEDICAID |