Provider Demographics
NPI:1689619660
Name:CENTRO DE SERVICIOS MEDICOS DE PENA POBRE
Entity Type:Organization
Organization Name:CENTRO DE SERVICIOS MEDICOS DE PENA POBRE
Other - Org Name:CENTRO DE SERVICIOS MEDICOS DE MUNICIPIO DE NAGUABO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:POMALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-874-3037
Mailing Address - Street 1:STREET 31
Mailing Address - Street 2:192
Mailing Address - City:NAGUABO
Mailing Address - State:PR
Mailing Address - Zip Code:00718
Mailing Address - Country:US
Mailing Address - Phone:787-874-3037
Mailing Address - Fax:787-874-3037
Practice Address - Street 1:STREET 31
Practice Address - Street 2:192
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718
Practice Address - Country:US
Practice Address - Phone:787-874-3037
Practice Address - Fax:787-874-3037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR30673261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR201648OtherPREFERRED HEALTH
PR6701184OtherHUMANA
PR9001119OtherCRUZ AZUL DE PUERTO RICO
PR00409OtherAMERICAN HEALTH
PR2991-1OtherPROSAM
PR89681OtherTRIPLE S
PR89681OtherTRIPLE S
PR6701184OtherHUMANA
PR=========OtherCOSVI