Provider Demographics
NPI:1649719824
Name:CORPORACION FONDO DEL SEGURO DEL ESTADO BAYAMON
Entity type:Organization
Organization Name:CORPORACION FONDO DEL SEGURO DEL ESTADO BAYAMON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:LASTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-782-8250
Mailing Address - Street 1:CARR ESTATAL 2 KM 8.5
Mailing Address - Street 2:BO JUAN SANCHEZ
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-0248
Mailing Address - Country:US
Mailing Address - Phone:787-782-8250
Mailing Address - Fax:787-782-8208
Practice Address - Street 1:CARRETERA ESTATAL 2 KM 8.5
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00960
Practice Address - Country:US
Practice Address - Phone:787-782-8250
Practice Address - Fax:787-782-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR120261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local