Provider Demographics
NPI:1013482066
Name:CONDADO WELLNESS CENTER PSC
Entity Type:Organization
Organization Name:CONDADO WELLNESS CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-230-7557
Mailing Address - Street 1:100 PASEO SAN PABLO STE 503
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-7028
Mailing Address - Country:US
Mailing Address - Phone:787-230-7557
Mailing Address - Fax:
Practice Address - Street 1:150 CALLE DE DIEGO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-3406
Practice Address - Country:US
Practice Address - Phone:787-230-7557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No173C00000XOther Service ProvidersReflexologistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1194244657Medicaid