Provider Demographics
NPI:1487105045
Name:WILDERNESS MEDICAL CORP
Entity type:Organization
Organization Name:WILDERNESS MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESSIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:DECASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-396-5183
Mailing Address - Street 1:830 CALLE VEREDA
Mailing Address - Street 2:URB. VALLE VERDE
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-3515
Mailing Address - Country:US
Mailing Address - Phone:787-396-5183
Mailing Address - Fax:
Practice Address - Street 1:14 CALLE PASARELL
Practice Address - Street 2:BAJOS
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698
Practice Address - Country:US
Practice Address - Phone:787-396-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15123261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1083838759Medicare PIN