Provider Demographics
NPI:1558664102
Name:CONCILIO DE SALUD INTEGRAL DE LOIZA, INC.
Entity Type:Organization
Organization Name:CONCILIO DE SALUD INTEGRAL DE LOIZA, INC.
Other - Org Name:CLINICA FAMILIAR DE CEIBA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:787-876-2042
Mailing Address - Street 1:CARRETERA #187 INT.#188 LOIZA, PR, 00772
Mailing Address - Street 2:BOX 509, LOIZA STATION
Mailing Address - City:LOIZA
Mailing Address - State:PR
Mailing Address - Zip Code:00772-0509
Mailing Address - Country:US
Mailing Address - Phone:787-876-2042
Mailing Address - Fax:787-256-1900
Practice Address - Street 1:CARRETERA #187 INT.#188 LOIZA, PR, 00772
Practice Address - Street 2:BOX 509, LOIZA STATION
Practice Address - City:LOIZA
Practice Address - State:PR
Practice Address - Zip Code:00772-0509
Practice Address - Country:US
Practice Address - Phone:787-876-2042
Practice Address - Fax:787-256-1900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCILIO DE SALUD INTEGRAL DE LOIZA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-20
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR401809Medicare PIN