Provider Demographics
NPI:1831302173
Name:POLICLINICA FAMILIAR SHALOM INC
Entity Type:Organization
Organization Name:POLICLINICA FAMILIAR SHALOM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FELICIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-291-0991
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-0903
Mailing Address - Country:US
Mailing Address - Phone:787-895-0914
Mailing Address - Fax:
Practice Address - Street 1:BO TERRANOVA CALLE MARGINAL DEL PARQUE
Practice Address - Street 2:
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678
Practice Address - Country:US
Practice Address - Phone:787-895-0914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
145207PE0004X
PR11789208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty