Basic Information
| Provider Information | |||||||||
| NPI: | 1871633842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRO PEDIATRICO METROPOLITANO DE SERVICIOS DE HABILITACION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191079 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877630550 | ||||||||
| FaxNumber: | 7877631093 | ||||||||
| Practice Location | |||||||||
| Address1: | HOSPITAL PEDIATRICO UNIVERSITARIO | ||||||||
| Address2: | CENTRO MEDICO DE PUERTO RICO | ||||||||
| City: | RIO PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877630550 | ||||||||
| FaxNumber: | 7877631093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 09/25/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIRIAM | ||||||||
| AuthorizedOfficialFirstName: | CHAVEZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7877630550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MHSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | 40 CNC NUM 93-060 | PR | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
No ID Information.