Provider Demographics
NPI:1003633991
Name:MEDINA S PRVENTIVE AND PRIMARY CARE, LLC
Entity type:Organization
Organization Name:MEDINA S PRVENTIVE AND PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DUBIEZEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-237-1235
Mailing Address - Street 1:HC 1 BOX 6664
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-9714
Mailing Address - Country:US
Mailing Address - Phone:787-237-1235
Mailing Address - Fax:
Practice Address - Street 1:CARR #2 KM 85.7 INT
Practice Address - Street 2:BO CARRIZALES
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-237-1235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service