Provider Demographics
NPI:1154379253
Name:CENTRO DE RADIOTERAPIA AUXILIO MUTUO, INC.
Entity type:Organization
Organization Name:CENTRO DE RADIOTERAPIA AUXILIO MUTUO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:787-758-2000
Mailing Address - Street 1:PO BOX 191227
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-1227
Mailing Address - Country:US
Mailing Address - Phone:787-771-7934
Mailing Address - Fax:787-771-7402
Practice Address - Street 1:735 AVE PONCE DE LEON
Practice Address - Street 2:STOP 37.5
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-5022
Practice Address - Country:US
Practice Address - Phone:787-771-7934
Practice Address - Fax:787-771-7402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7582OtherPALIC
PR9190184OtherHUMANA
PR100593OtherCRUZ AZUL
PR660312302OtherMAPFRE
PR=========OtherSOCIOS