Provider Demographics
NPI:1407149206
Name:CORP. FONDO DEL SEGURO DEL ESTADO
Entity Type:Organization
Organization Name:CORP. FONDO DEL SEGURO DEL ESTADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY TECHNICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-848-4545
Mailing Address - Street 1:APARTADO #949, PONCE
Mailing Address - Street 2:AVE. SANTIAGO DE LOS CABALLEROS #2136
Mailing Address - City:PONCE
Mailing Address - State:P.R.
Mailing Address - Zip Code:00733
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2136 AVE, SANTIAGO DE LOS CABALLEROS
Practice Address - Street 2:APARATADO 949
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00733
Practice Address - Country:US
Practice Address - Phone:787-848-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRX251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management