Provider Demographics
NPI:1356506844
Name:GRUPO MEDICO SAN CARLOS
Entity Type:Organization
Organization Name:GRUPO MEDICO SAN CARLOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-268-4433
Mailing Address - Street 1:BOX 19209
Mailing Address - Street 2:FDEZ JUNCOS STATION
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910-1209
Mailing Address - Country:US
Mailing Address - Phone:787-268-4433
Mailing Address - Fax:787-726-1828
Practice Address - Street 1:1866 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2010
Practice Address - Country:US
Practice Address - Phone:787-268-4433
Practice Address - Fax:787-726-1828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR09-B-3148261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0083901Medicare PIN