Provider Demographics
NPI:1902201742
Name:CENTRO MEDICINA INTEGRAL DR. JIMENEZ CSP
Entity Type:Organization
Organization Name:CENTRO MEDICINA INTEGRAL DR. JIMENEZ CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-604-3845
Mailing Address - Street 1:C 11 CALLE 3
Mailing Address - Street 2:URB FLAMBOYAN
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674
Mailing Address - Country:US
Mailing Address - Phone:787-854-5828
Mailing Address - Fax:
Practice Address - Street 1:C11 CALLE 3
Practice Address - Street 2:URB FLAMBOYAN
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-5828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H55604Medicare UPIN