Basic Information
| Provider Information | |||||||||
| NPI: | 1952967564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRO DE SALUD CONDUCTUAL MENONITA CIMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1650 | ||||||||
| Address2: | |||||||||
| City: | CIDRA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007391650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341715 | ||||||||
| Practice Location | |||||||||
| Address1: | LA FUENTE TOWN CENTER | ||||||||
| Address2: | AVE PEDRO ALBIZU CAMPOS MARGINAL SUITE 109 | ||||||||
| City: | GUAYAMA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007840011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874371700 | ||||||||
| FaxNumber: | 7874341715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2019 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | VASQUEZ RIVERA | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7874341700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRO DE SALUD CONDUCTUAL MENONITA CIMA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 6 | 01 | PR | LICENCE OF HEALTH DEPARTMENT | OTHER |