Provider Demographics
NPI:1104907682
Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO INC
Entity type:Organization
Organization Name:ATLANTIS HEALTH CARE GROUP PUERTO RICO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUBETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-292-7979
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:ST. JUST STATION
Mailing Address - City:SAINT JUST
Mailing Address - State:PR
Mailing Address - Zip Code:00978-1350
Mailing Address - Country:US
Mailing Address - Phone:787-292-7979
Mailing Address - Fax:787-292-7999
Practice Address - Street 1:CALLE ANICETO DIAZ INTERSECCION 876
Practice Address - Street 2:EXPRESO TRUJILLO ALTO
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00978
Practice Address - Country:US
Practice Address - Phone:787-292-7979
Practice Address - Fax:787-292-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLIC #23 CNC 05-260261QE0700X
PRLIC #12 CNC 04-126261QE0700X
PRLIC #19 CNC 01-107261QE0700X
PRLIC #37 CNC 02-166261QE0700X
PRLIC #25 CNC 01-108261QE0700X
PR27 CNC 02-162261QE0700X
PRLIC NUM 36261QE0700X
PRLIC #28 CNC 03-278261QE0700X
PRLIC. #44 CNC12-087261QE0700X
PRLIC # 46 CNC 13-051261QE0700X
PRLIC #3 CNC 01-109261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR402547Medicare Oscar/Certification
PR402510Medicare Oscar/Certification
PR402519Medicare Oscar/Certification
PR402521Medicare Oscar/Certification
PR402541Medicare Oscar/Certification
PR402548Medicare Oscar/Certification
PR402527Medicare Oscar/Certification
PR402536Medicare Oscar/Certification
PR402539Medicare Oscar/Certification
PR402533Medicare Oscar/Certification
PR402552Medicare Oscar/Certification