Provider Demographics
NPI:1841320082
Name:CENTRO PEDIATRICO COUNTRY CLUB
Entity type:Organization
Organization Name:CENTRO PEDIATRICO COUNTRY CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:FONTANET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-769-5500
Mailing Address - Street 1:GO7 AVE ROBERTO SANCHEZ VILELLA
Mailing Address - Street 2:COUTRY CLUB
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00982-2678
Mailing Address - Country:US
Mailing Address - Phone:787-769-5500
Mailing Address - Fax:787-762-9110
Practice Address - Street 1:GO7 AVE ROBERTO SANCHEZ VILELLA
Practice Address - Street 2:COUTRY CLUB
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00982-2678
Practice Address - Country:US
Practice Address - Phone:787-769-5500
Practice Address - Fax:787-762-9110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty