Provider Demographics
NPI:1285050393
Name:PEQUENO CAMPEON DE JESUS INC
Entity type:Organization
Organization Name:PEQUENO CAMPEON DE JESUS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EURELIA
Authorized Official - Middle Name:PEREZ
Authorized Official - Last Name:OLIVO
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:787-846-5724
Mailing Address - Street 1:5 CARR 140 # KM
Mailing Address - Street 2:BARRIO LLANADAS
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-2806
Mailing Address - Country:US
Mailing Address - Phone:787-846-5724
Mailing Address - Fax:787-846-5724
Practice Address - Street 1:140 BO LLANADAS
Practice Address - Street 2:
Practice Address - City:BARCELONETA
Practice Address - State:PR
Practice Address - Zip Code:00617-2927
Practice Address - Country:US
Practice Address - Phone:787-846-5724
Practice Address - Fax:787-846-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171R00000X, 172M00000X, 174400000X, 235Z00000X, 261QM0855X, 261QP2000X
PR1221235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
No172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty