Provider Demographics
NPI:1013408459
Name:GRUPO MEDICO JATIBONICO LLC
Entity Type:Organization
Organization Name:GRUPO MEDICO JATIBONICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOAQUIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FELICIANO
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:787-625-2500
Mailing Address - Street 1:URB. CARIBE 1551
Mailing Address - Street 2:CALLE ALDA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-625-2500
Mailing Address - Fax:787-625-0438
Practice Address - Street 1:65 CALLE PEDRO ROSARIO
Practice Address - Street 2:
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705-3237
Practice Address - Country:US
Practice Address - Phone:787-625-2500
Practice Address - Fax:787-625-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center