Provider Demographics
NPI:1083993745
Name:CENTRO DE VACUNACION
Entity Type:Organization
Organization Name:CENTRO DE VACUNACION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:J
Authorized Official - Last Name:GANDARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-552-1219
Mailing Address - Street 1:P O BOB 1357
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-1357
Mailing Address - Country:US
Mailing Address - Phone:787-552-1219
Mailing Address - Fax:787-745-0108
Practice Address - Street 1:CALLE MUNOZ RIVERA # 3
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-1357
Practice Address - Country:US
Practice Address - Phone:787-552-1219
Practice Address - Fax:787-745-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care