Provider Demographics
NPI:1093151631
Name:CDT DE TOA ALTA PUEBLO
Entity Type:Organization
Organization Name:CDT DE TOA ALTA PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAJOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEMENTE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGOSTO LUGARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-870-2100
Mailing Address - Street 1:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-1649
Mailing Address - Country:US
Mailing Address - Phone:787-870-2100
Mailing Address - Fax:787-876-2422
Practice Address - Street 1:16 CALLE BARCELO
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-2444
Practice Address - Country:US
Practice Address - Phone:787-870-8690
Practice Address - Fax:787-870-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1609917848Medicaid