Provider Demographics
NPI:1639509714
Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO, INC.
Entity Type:Organization
Organization Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO, INC.
Other - Org Name:RENAL CENTRE OF SAN SEBASTIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUBETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-292-7979
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:ST. JUST STATION
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-1350
Mailing Address - Country:US
Mailing Address - Phone:787-292-7979
Mailing Address - Fax:787-292-7999
Practice Address - Street 1:BO. BAHOMAMEY
Practice Address - Street 2:AVE. EMERITO ESTADA KM 21.8 PR-125
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685-2285
Practice Address - Country:US
Practice Address - Phone:787-292-7979
Practice Address - Fax:787-292-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR#37261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038203000Medicaid