Provider Demographics
NPI:1922594282
Name:PREVNTIVE MEDICAL ALLIANCE INC
Entity Type:Organization
Organization Name:PREVNTIVE MEDICAL ALLIANCE INC
Other - Org Name:PREVENTIVE MEDICAL ALLIANCE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HIRAM
Authorized Official - Middle Name:JOSUE
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-431-6710
Mailing Address - Street 1:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-0122
Mailing Address - Country:US
Mailing Address - Phone:787-975-2555
Mailing Address - Fax:
Practice Address - Street 1:AVE LOS ROTARIOS CARR 4415 KM 1.5
Practice Address - Street 2:SUITE 2
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602
Practice Address - Country:US
Practice Address - Phone:787-975-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14432171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty