Provider Demographics
NPI:1508197765
Name:HUMACAO HEALTH CLINIC PHG
Entity Type:Organization
Organization Name:HUMACAO HEALTH CLINIC PHG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IDALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTO RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-368-9787
Mailing Address - Street 1:400 CALLE CALAF STE 361
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-1314
Mailing Address - Country:US
Mailing Address - Phone:787-993-3535
Mailing Address - Fax:787-522-0649
Practice Address - Street 1:CALLE FLOR GERENA
Practice Address - Street 2:#6 SUR
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-656-9939
Practice Address - Fax:787-522-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR660638103OtherOPTION HEALTH GROUP, INC