Provider Demographics
NPI:1285648279
Name:PONCE MEDICAL SCHOOL FOUNDATION
Entity Type:Organization
Organization Name:PONCE MEDICAL SCHOOL FOUNDATION
Other - Org Name:CENTRO DE SALUD CONDUCTUAL GUAYAMA
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:787-840-2575
Mailing Address - Street 1:PO BOX 7004
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7004
Mailing Address - Country:US
Mailing Address - Phone:787-840-2575
Mailing Address - Fax:787-840-8391
Practice Address - Street 1:NIEVES PETTITE MALL LOCAL # 2
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00785
Practice Address - Country:US
Practice Address - Phone:787-866-2726
Practice Address - Fax:787-866-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR008-5035Medicare ID - Type Unspecified