Basic Information
| Provider Information | |||||||||
| NPI: | 1871633933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNICIPIO DE ISABELA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRO ISABELINO MEDICINA AVANZADA - RX | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 737 | ||||||||
| Address2: | |||||||||
| City: | ISABELA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878302705 | ||||||||
| FaxNumber: | 7878300465 | ||||||||
| Practice Location | |||||||||
| Address1: | AVE. AGUSTIN R. CALERO. | ||||||||
| Address2: | KM 1.1. ISABELA | ||||||||
| City: | ISABELA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878302705 | ||||||||
| FaxNumber: | 7878300465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN DERDYS | ||||||||
| AuthorizedOfficialFirstName: | GISSELLE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRADOR | ||||||||
| AuthorizedOfficialTelephone: | 7878302705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | TRX | PR | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.