Provider Demographics
NPI:1710325063
Name:CONSULTORIO MEDICO VILLA BLANCA, PSC
Entity Type:Organization
Organization Name:CONSULTORIO MEDICO VILLA BLANCA, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALFONSO MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:939-325-3907
Mailing Address - Street 1:AVE 200 RAFAEL CORDERO
Mailing Address - Street 2:SUIT 140 PMB 494
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-9998
Mailing Address - Country:US
Mailing Address - Phone:939-325-3907
Mailing Address - Fax:787-744-0280
Practice Address - Street 1:10 AVE LUIS MUNOZ MARIN
Practice Address - Street 2:VILLA BLANCA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-1922
Practice Address - Country:US
Practice Address - Phone:939-325-3907
Practice Address - Fax:787-744-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center