Basic Information
| Provider Information | |||||||||
| NPI: | 1891424891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPITAL MENONITA HUMACAO INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RED AMBULATORIA MENONITA (CENTRO DE DIAGNOSTICO Y TRATAMIENTO) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1650 | ||||||||
| Address2: | |||||||||
| City: | CIDRA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007391650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341711 | ||||||||
| Practice Location | |||||||||
| Address1: | AVE. BOULEVARD SUR, TORRE III | ||||||||
| Address2: | BOULEVARD DEL RIO OFFICE CENTER BO RIO ABAJO | ||||||||
| City: | HUMACAO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007928888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VASQUEZ RIVERA | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7874341700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 88 | 01 | PR | LICENCIA OPERACIONAL | OTHER |