Provider Demographics
NPI:1316750854
Name:SOUTHWESTERN PRIMARY CARE LLC
Entity type:Organization
Organization Name:SOUTHWESTERN PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILMER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVILA GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-590-5451
Mailing Address - Street 1:HC 1 BOX 1637
Mailing Address - Street 2:
Mailing Address - City:BOQUERON
Mailing Address - State:PR
Mailing Address - Zip Code:00622-9619
Mailing Address - Country:US
Mailing Address - Phone:787-590-5451
Mailing Address - Fax:
Practice Address - Street 1:CARR. 101 KM. 16.2 SECTOR LAS ARENAS
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623
Practice Address - Country:US
Practice Address - Phone:787-590-5451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-29
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1033755913Medicaid