Provider Demographics
NPI:1912997768
Name:COSTA SALUD COMMUNITY HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:COSTA SALUD COMMUNITY HEALTH CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-823-5555
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:PR
Mailing Address - Zip Code:00677
Mailing Address - Country:US
Mailing Address - Phone:787-823-5555
Mailing Address - Fax:787-823-2990
Practice Address - Street 1:CALLE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:PR
Practice Address - Zip Code:00677
Practice Address - Country:US
Practice Address - Phone:787-823-5555
Practice Address - Fax:787-823-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR57261QC1500X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0038354Medicare ID - Type UnspecifiedLABORATORY
PR0010116Medicare ID - Type UnspecifiedOPD
PR=========Medicaid
PR=========-1Medicaid
PR=========-VMedicaid
PR10116OtherPROVIDER
PR0010116Medicare ID - Type UnspecifiedOPD