Provider Demographics
NPI:1932136470
Name:POLICLINICA LA FAMILIA TOA ALTA, INC.
Entity Type:Organization
Organization Name:POLICLINICA LA FAMILIA TOA ALTA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ITZA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHEVRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-870-7121
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954-0867
Mailing Address - Country:US
Mailing Address - Phone:787-870-7070
Mailing Address - Fax:787-870-6382
Practice Address - Street 1:10ST #G-21, URB. VILLA MATILDE
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-870-7070
Practice Address - Fax:787-870-6382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13168174400000X
PR14703174400000X
PR7078174400000X
PR25322085R0202X
PR14247302R00000X
PR10413302R00000X
PR9462302R00000X
PR5109302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR83851Medicare ID - Type UnspecifiedMULTIDICIPINARY GROUP