Provider Demographics
NPI:1922293240
Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO INC
Entity Type:Organization
Organization Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO INC
Other - Org Name:RENAL CENTER OF ISABELA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUBETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-292-7979
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:SAINT JUST STATION
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-1350
Mailing Address - Country:US
Mailing Address - Phone:787-292-7979
Mailing Address - Fax:787-872-8429
Practice Address - Street 1:CARRETERA #2 KM 113.5
Practice Address - Street 2:BO. GUERRERO
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-0000
Practice Address - Country:US
Practice Address - Phone:787-292-7979
Practice Address - Fax:787-872-8429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLIC #41 CNC 07-179261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR660675890OtherIRS
PR402537Medicare Oscar/Certification