Provider Demographics
NPI:1942742879
Name:CLINICA DE SERVICIOS MEDICOS Y COMPLEMENTARIOS
Entity Type:Organization
Organization Name:CLINICA DE SERVICIOS MEDICOS Y COMPLEMENTARIOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MELENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-218-0245
Mailing Address - Street 1:PO BOX 10329
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-1329
Mailing Address - Country:US
Mailing Address - Phone:787-850-0211
Mailing Address - Fax:787-850-0220
Practice Address - Street 1:59 FONT MARTELO
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00792
Practice Address - Country:US
Practice Address - Phone:787-850-0211
Practice Address - Fax:787-850-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4184813261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2-7725Medicare UPIN