Provider Demographics
NPI:1033414966
Name:IPA MUNICIPAL TOA ALTA 357
Entity Type:Organization
Organization Name:IPA MUNICIPAL TOA ALTA 357
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODRIGUEZ
Authorized Official - Middle Name:BENITEZ
Authorized Official - Last Name:JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-870-8690
Mailing Address - Street 1:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00726
Mailing Address - Country:UM
Mailing Address - Phone:787-870-8690
Mailing Address - Fax:787-747-9300
Practice Address - Street 1:CALLE BARCELO 16
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-0000
Practice Address - Country:US
Practice Address - Phone:787-745-0708
Practice Address - Fax:787-747-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========Medicaid