Provider Demographics
NPI:1073362760
Name:MANUEL MEDINA
Entity type:Organization
Organization Name:MANUEL MEDINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIELY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-607-1591
Mailing Address - Street 1:PO BOX 1498
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-1498
Mailing Address - Country:US
Mailing Address - Phone:787-807-0900
Mailing Address - Fax:
Practice Address - Street 1:ROAD PR-2 MARGINAL D-10
Practice Address - Street 2:URB. VILLA REAL
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00694
Practice Address - Country:US
Practice Address - Phone:787-807-0900
Practice Address - Fax:787-855-2729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH WESTERN RADIOLOGY SERVICES PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1780652594Medicaid