Provider Demographics
NPI:1700024015
Name:UNIVERSAL SA CORP.
Entity Type:Organization
Organization Name:UNIVERSAL SA CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTIGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-513-5752
Mailing Address - Street 1:2520 SW 22ND ST
Mailing Address - Street 2:SUITE 2-070
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3438
Mailing Address - Country:US
Mailing Address - Phone:305-513-5752
Mailing Address - Fax:
Practice Address - Street 1:2520 SW 22ND ST
Practice Address - Street 2:SUITE 2-070
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3438
Practice Address - Country:US
Practice Address - Phone:305-513-5752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL302F00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization