Provider Demographics
NPI:1437457967
Name:POLICLINICA LA FAMILIA DE TOA ALTA INC
Entity Type:Organization
Organization Name:POLICLINICA LA FAMILIA DE TOA ALTA INC
Other - Org Name:CENTRO DE VACUNACION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ITZA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHEVRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-870-7070
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954
Mailing Address - Country:US
Mailing Address - Phone:787-870-7070
Mailing Address - Fax:787-870-6382
Practice Address - Street 1:CALLE 10 G21 VILLA MATILDE
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-870-7070
Practice Address - Fax:787-870-6382
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INCORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9462261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR008-3851Medicare PIN