Provider Demographics
NPI:1639393697
Name:IPA POLICLINICA VILLA LOS SANTOS
Entity Type:Organization
Organization Name:IPA POLICLINICA VILLA LOS SANTOS
Other - Org Name:IPA 029 POLICLINICA VILLA LOS SANTOS
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRADORA
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:GONZALEZ
Authorized Official - Last Name:AGRASO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-817-3144
Mailing Address - Street 1:PO BOX 9091
Mailing Address - Street 2:COTTO STATION
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613-9091
Mailing Address - Country:US
Mailing Address - Phone:787-879-1585
Mailing Address - Fax:787-879-4315
Practice Address - Street 1:V1 CALLE 16
Practice Address - Street 2:URB. VILLA LOS SANTOS
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-3112
Practice Address - Country:US
Practice Address - Phone:787-879-1585
Practice Address - Fax:787-879-4315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherTAX ID