Provider Demographics
NPI:1407998859
Name:MIGRANT HEALTH CENTER WESTERN REGION,INC
Entity Type:Organization
Organization Name:MIGRANT HEALTH CENTER WESTERN REGION,INC
Other - Org Name:MIGRANT HEALTH CENTER WESTERN REGION,INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR EJECUTIVO
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:SERRANO
Authorized Official - Last Name:CARABALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-805-2900
Mailing Address - Street 1:P O BOX 190
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681
Mailing Address - Country:US
Mailing Address - Phone:787-805-2900
Mailing Address - Fax:787-834-1924
Practice Address - Street 1:23 BO MONTALVA
Practice Address - Street 2:
Practice Address - City:ENSENADA GUANICA
Practice Address - State:PR
Practice Address - Zip Code:00647
Practice Address - Country:US
Practice Address - Phone:787-821-3377
Practice Address - Fax:787-821-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR932291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherNUM PATRONAL
PR0031095Medicare ID - Type UnspecifiedNUM PROVEEDOR SSS
PR=========OtherNUM PATRONAL