Provider Demographics
NPI:1760724645
Name:OFICINA DE VACUNACION SANTA JUANITA
Entity Type:Organization
Organization Name:OFICINA DE VACUNACION SANTA JUANITA
Other - Org Name:IVAN CEREZO DE LA ROSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:PALMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-780-0391
Mailing Address - Street 1:DB35 CALLE DAMASCO
Mailing Address - Street 2:URB SANTA JUANITA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-5313
Mailing Address - Country:US
Mailing Address - Phone:787-780-0391
Mailing Address - Fax:787-787-6403
Practice Address - Street 1:DB35 CALLE DAMASCO
Practice Address - Street 2:URB SANTA JUANITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-780-0391
Practice Address - Fax:787-787-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR522463261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8-2133PRMedicare PIN
PRE81957Medicare UPIN