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121 Ave Ponce De Leon Bo Amelia Guaynabo PR 00965-5602 | |
| (787) 773-1133 | |
| (787) 919-3956 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 121 Ave Ponce De Leon, Guaynabo, Puerto Rico |
| Authorized Official Name and Position | Ivonne Rivera (CEO) |
| Authorized Official Contact | 7872684171 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 14457 San Juan PR 00916-4457 Ph: (787) 268-4171 | 121 Ave Ponce De Leon Bo Amelia Guaynabo PR 00965-5602 Ph: (787) 773-1133 |
| NPI Number | 1477191096 |
|---|---|
| Provider Enumeration Date | 12/13/2019 |
| Last Update Date | 07/10/2024 |
| Medicare PECOS PAC ID | 3870629579 |
|---|---|
| Medicare Enrollment ID | O20200320002786 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1477191096 | NPI | - | NPPES |
| 037910500 | Medicaid | PR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Secondary |
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