Provider Demographics
NPI:1235411711
Name:SAN JUAN PRIMARY HEALTH CARE PROVIDERS, LLC
Entity Type:Organization
Organization Name:SAN JUAN PRIMARY HEALTH CARE PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:ELI
Authorized Official - Last Name:MEDINA-MANGUAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-760-0770
Mailing Address - Street 1:LE 93 VIA PARIS L'ANTIGUA
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-760-0770
Mailing Address - Fax:787-760-0770
Practice Address - Street 1:CARRETERA 844 KM 4.2 BO. CUPEY BAJO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-760-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty